Skip to content
Limb Loss Questionnaire
Confidentiality
Read Privacy Statement
*
Yes
No
Privacy Statement
Your privacy is our priority. The information you provide in this questionnaire will be treated with the strictest confidence and is protected under data protection laws (including GDPR). The details you share will be used solely for [e.g., assessing your needs, supporting you, processing your NHS funding application if asked to by you]. Your personal data will be stored securely and will not be shared with anyone else without your explicit consent. By completing and submitting this form, you agree that we are processing your sensitive health data for the reasons outlined above. If you have any questions about how your information is handled, please get in touch with us at client.services@disabilityplus.co.uk.
Your Details
Your Name?
*
PostCode?
*
Date of Birth
*
Email Address
*
Telephone/Text
*
Relationship?
Single
Divorced
Live-In-Partner
Married
Employment?
Employed?
Yes
No
Work Hours
Full time
Part time
Are You Medically or Physically Able to Work?
Yes
No
Other
Other
Employer
Employer supportive
Can no longer do my job
Will lose my job
Will become unemployed
Employment
Anything to add about employer or why you have become unemployed
Loss of Limb Questions?
Status?
*
Pre-Amputation
New Amputation
Long Term Amputee
Other
Other
When?
Do you know when the amputation will happen?
What year?
If this year, what month?
Type of amputation?
Leg (below knee)
Leg (above knee)
Both Legs (Below Knee)
Both Legs (Above Knee)
Both Legs (Above and Below Knee)
One Arm
Both Arms
One Hand
Both Hands
Circumstance?
Planned Medical Procedure
Medical Negligence
Road Traffic Accident
Personal Injury at Work
Leisure Activity
Other
Other
Mobility Device?
*
Not Needed
Crutches
Hoist
Wheelchair User
Motorised Wheelchair
Supporting Frame
Other
Other
As best you can describe what happened?
How you have or are about to lose your limb. What are the circumstances that have caused the limb loss.
Do you have phantom limb loss?
No
Yes
Other
Other
Have you received occupational therapies
Yes
No
Occupational Therapy by who?
Company or NHS or Private?
What year?
Occupational Therapy Year
Have you started the pre-prosthetic stage?
Yes
No
N/A
Have you had your fitting?
Yes
No
N/A
Any, Additional Disabilities
Do you have any additional disabilities?
No
Ataxia
Autism
Cognitive Problems
EDS
Epilepsy
Hearing Loss
MS
Sight Loss
Spinal Injury
TBI
Other
Other
Hearing Loss
Mild
Moderate
Severe
Deaf/BSL User
Other
Other
Spinal Injury
Complete
Incomplete
Other
Other
Sight Loss
Mild
Moderate
Severe
Blind
Other
Other
Medical
Any Medical Issues?
Yes
No
Excluding Limb Loss
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Anything to add Medically?
Other?
Carer
Do you have a carer?
No
Yes
Other
Other
Is you carer?
Parent
Partner
Social Services
Other
Other
Carer hours?
1-4 hours daily
5 – 8 hours daily
Live-in
Assisted living at home
Assisted living (social services)
Other
Other
If you are human, leave this field blank.
Next
Δ
Loading Comments...
Write a Comment...
Email (Required)
Name (Required)
Website
