Questionnaire for Disabilities

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.

Address & Contact

Your Name?

PostCode?

Date of Birth

Gender

How would you like to be known as?

Headline Disability or Topic

Funding

Self-Paid (quick start)

Self-Paid & NHS Funding Application

NHS Funding Application Only

Employment Support

Other

What Would You Like Help With?

Multi-Select Available

Addictions

Anger

Anxiety

Body Dysmorphia

Chronic Fatigue Syndrome

Chronic Pain

Depression

Dissociative Disorders

Health Anxiety

Fibromyalgia

OCD

Continued

Psychosis

Panic Disorder

Personality Disorder

Phobias

PTSD

Social Anxiety

Stress

Suicidal Thought

Self-Harm Thoughts

Other

Assistive Devices

Mobility Device?

Not Needed

Crutches

Supporting frame

Tilt-in-space

Manuel wheelchair

Standing wheelchair

Motorised wheelchair

Standing frame

Other

Assistive Technology?

Not Needed

Electronic communication board

Low-tech communication board

Speech-generating device

Eye-tracking device

Typing and writing devices

Hearing Aids

Cochlear Implant

Other

Multi-select

Disability, Injury or Issue?

Do you have a medical health problems?

No

Yes

What is your medical problem? (multi-select)

Alzheimers

Arthritis

Asthma

Blood Pressure

Cancer

Infectious Disease

Lung Conditions

Diabetes

Heart Issues

Stroke

Other

Do you take medication?

None

Antidepressants

Antipsychotics

Anti-Anxiety

Heart Medication

Diabetes Medication

Mood Stabilisers

Stimulants

Other

Please write a brief outline of your medical problem

Is your problem related to food?

No

Yes

Please write a brief outline of your food problem

Is your problem related to sight loss?

No

Yes

Including USHER

Please write a brief outline of your sight loss effects you?

Is your problem related to ADHD or ASD?

No

Yes

Please write a brief outline of how your ADHD or ASD effects you?

Is your problem related to addictions?

No

Yes

Please write a brief outline of your addictions problem

Is your problem related to phobias?

No

Yes

Please write a brief outline of your phobia problem

Is your problem related to a Injury?

No

Yes

Please write a brief outline of your injury problem

Is your problem related to a long term condition?

No

Yes

Please write a brief outline of your long term condition

Is your problem related to Dysplasia

No

Yes

Name of Dysplasia

Please write a brief outline of your Dysplasia

How if effects you pysically.

Is your problem related to a speech impairment?

No

Yes

Including Tourette’s

Please write a brief outline of your Speech Impairment

Is your problem related to a genetic condition?

No

Yes

Please write a brief outline of your genetic condition

Is your problem related to a neurological issue?

No

Yes

Including FND

Please write a brief outline of your neurological problem

Is your problem related to sudden or progressive hearing loss?

No

Yes

Please write a brief outline of how the hearing loss started and in which or both ears.

Do you have tinnitus?

No

Yes

Please write a brief outline of how the tinnitus effects you, ie which ear etc

Is your problem related to assault?

No

Yes

Please write in type of assault (not details of the assault)

Please insert type of assault

Is your problem related to trauma?

No

Yes

Please explain how the trauma affects you?

Is your problem related to epilepsy?

No

Yes

Please explain frequency and type of epilepsy

Is your problem related to chronic pain?

No

Yes

Please write in type and effects of chronic pain

Do you have any of these conditions?

Please Select? Multi-select available

Have you been diagnosed by GP or other medical professional?

If yes, When and who by? also how Autism affects you?

Legal

Are you in dispute with any authorities or persons?

Is your dispute going to court or litigation?

No

Yes

Other

Briefly explain the dispute.

Briefly explain at what stage you are at with the courts or litigation and any possible timelines.

Employment

Are you medically or physically able to work?

Yes

No

Other

Carer Questions?

Do you have a carer?

No

Yes

Other

Is you carer?

Parent

Partner

Social Services

Other

Carer hours?

Anything to add about carer?