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Muscular Dystrophy Questionnaire
Confidentiality
Read Privacy Statement
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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.
Who is Completing Form
Please tell us who is completing the form?
*
Myself
Carer
Mother/Father
Family memeber
Social services
Other
Other
I would prefer not to answer question
Referer Details
Are you helping them with the form
Yes
No
I would prefer not to answer question
With person
Are you completing the form
Yes
No
I would prefer not to answer question
For them
Have you got permission?
Yes
No
I would prefer not to answer question
From the referred?
Your name?
*
Referrer
Your email?
*
Referrer
Name & Contact Details
Person who wants counselling
Your Name?
*
Person who wants counselling
Postcode?
*
Date of Birth
*
Email?
*
Client
Family/Employment
Status?
Single
Divorced
Live-In-Partner
Married
I would prefer not to answer question
Children?
Yes
No
I would prefer not to answer question
under 18?
Employed?
Yes
No
I would prefer not to answer question
Status
Full-Time
Part-Time
I would prefer not to answer question
Medically or Physically Able to Work?
Yes
No
Other
I would prefer not to answer question
Medically or Physically Able to Work?
Retired or Student?
No
Student
Retired
I would prefer not to answer question
What Would You Like Help With?
Multi-Select Available
Ableism
Addictions
Anger
Anxiety
Body Dysmorphia
Chronic Fatigue Syndrome
Chronic Pain
Depression
Dissociative Disorders
Health Anxiety
Fibromyalgia
Continued
OCD
Psychosis
Panic Disorder
Personality Disorder
Phobias
PTSD
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
About me?
Your Muscular Dystrophy/Atrophy?
*
Duchenne
Becker
Congenital
Myotonic
Limb-Girdle
Facioscapulohumeral
Emery–Dreifuss
Distal
Oculopharyngeal
Collagen Type VI-Related
Spinal Muscular Atrophy (SMA)
Other
Your Muscular Dystrophy/Atrophy?
Other Disabilities?
*
None
Autism
Epilepsy
Hearing Loss
Medical Illness
Sight Loss
Other
Other
Severity
Hearing Loss
Mild
Moderate
Severe
Deaf/BSL User
Other
Other
Sight Loss
Mild
Moderate
Severe
Blind
Other
Other
Epilepsy Severity?
Mild
Moderate
Severe
Other
Other
What medical illness?
What is the other?
Mobility & Communication
Mobility Device?
*
Not Needed
Crutches
Supporting frame
Tilt-in-space
Manuel wheelchair
Standing wheelchair
Motorised wheelchair
Standing frame
Other
I would prefer not to answer question
Mobility Device?
Communication Devices?
*
Not Needed
Electronic communication board
Low-tech communication board
Speech-generating device
Eye-tracking device
Typing and writing devices
Hearing Aids
Cochlear Implant
Other
I would prefer not to answer question
Communication Devices?
Any other?
*
No
Yes
Other
I would prefer not to answer question
Any other?
Communication Devices?
Not Needed
Electronic communication board
Low-tech communication board
Speech-generating device
Eye-tracking device
Typing and writing devices
Hearing Aids
Cochlear Implant
Other
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Communication Devices?
Any other?
No
Yes
Other
I would prefer not to answer question
Any other?
Communication Devices?
Not Needed
Electronic communication board
Low-tech communication board
Speech-generating device
Eye-tracking device
Typing and writing devices
Hearing Aids
Cochlear Implant
Other
I would prefer not to answer question
Communication Devices?
Carer
Do you have a carer?
No
Yes
Other
I would prefer not to answer question
Do you have a carer?
Does Carer do daily tasks?
Yes, Carer Does
Most of the time
When I ask for help
I would prefer not to answer question
Carer Reliance?
Personal Hygiene?
I can wash myself
Carer helps me
Carer does for me
Other
I would prefer not to answer question
Personal Hygiene?
Shopping?
I can do shopping
Carer does shopping for me
Only when I need help
Other
I would prefer not to answer question
Shopping?
House cleaning?
I can do it myself
Carer helps when I ask
Carer cleans house
Other
I would prefer not to answer question
House cleaning?
Carer is?
Multiple carers (family)
One carer (family)
Multiple carers (social services)
One carer (social services)
Other
I would prefer not to answer question
Carer is?
Carer hours?
1-4 hours daily
5 – 8 hours daily
Live-in
Assisted living at home
Assisted living (social services)
Other
I would prefer not to answer question
Carer hours?
Anything to add about carer?
Health
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
I would prefer not to answer question
Medication?
Any Medical Issues?
Yes
No
I would prefer not to answer question
Excluding MD
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Anything to add Medically?
If you are human, leave this field blank.
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