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Spina Bifida Questionnaire
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Policy
All information entered on this form is private and confidential. As a mental health service, we prioritise your privacy and the confidentiality of your personal and health information. The details you provide will only be used to support your care and treatment and will not be shared with any third parties without your explicit consent. Your trust is important to us, and we are committed to protecting your privacy in accordance with applicable privacy laws and professional standards.
You are?
Name
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Your Post Code
Date of Birth
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Your Email
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Practice name
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GP
Practice postcode
GP
Doctor name (if known)
Type
My Spina Bifida
Occulta
Closed neural tube defects
Myelomeningocele
Meningocele
Other
Other
Other
Explain as best you can why you selected “other”.
Symptoms
Please select if any of these apply to you.
Weakness or paralysis in the legs
Difficulty with walking
Bone and joint problems
Lack of bowel control
Lack of bladder control
Hydrocephalus
Skin problems
Tethered cord syndrome
Chiari II malformation
Other
Other
Bone and joint problems
Dislocated or deformed joints
Bone fractures
Misshapen bones
Abnormal curvature of the spine (scoliosis)
Other
Other
Bowel and Bladder Problems
Urinary incontinence
Urinary tract infections (UTIs)
Kidney problems
Other
Other
Hydrocephalus
Learning Problems
Poor Vision
Lack of Coordination
Other
Other
Skin Problems
Burns
Sores
Infections
Other
Other
Your Care
Do you have carer?
Not Needed
Partner
Sibling
Social Services
Other
Other
Are you in care?
No
Supportive Care
Palliative Care
Hospice Care
Other
Other
In Care Hours
Part-time
Full-time
Live-in
Other
Other
Carer Hours
Part-time
Full-time
Live-in
Other
Other
If you are human, leave this field blank.
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