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Spinal Cord Injury Questionnaire
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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
*
Your Post Code
Date of Birth
*
Your Email
*
Practice name
GP
Practice postcode
GP
Doctor name (if known)
Your SCI
My Spinal Cord Injury
Tetraplegia
Paraplegia
Incomplete
Other
Other
Other
Explain as best you can why you selected “other”.
Tetraplegia
Vertebrae?
C1
C2
C3
C4
C5
C6
C7
C8
Other
Other
Other
Vertebrae?
T1 -12
L1-L5
S1-S5
Other
Other
Loss/Pain (multi-select)
Loss of or altered sensation, including the ability to feel heat, cold and touch
Loss of bowel or bladder control
Exaggerated reflex activities or spasms
Changes in fertility
Changes in sexual function, sexual sensitivity
Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
Difficulty breathing, coughing or clearing secretions from your lungs
Other
Other
Spasms
Sudden, involuntary jerking when bending (chest, back)
Sudden, involuntary jerking when extending (straightening)
Hyperactive (overactive) reflexes, such as a muscle spasm when you are lightly touched
Stiff or tight muscles at rest, so that it is difficult to relax or stretch your muscles
Muscle tightness during activity, making it difficult for you to control your movement.
Other
Other
Fertility
Can have children
Cannot have children
Other
Other
Mental Health Effects (fertility)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Why other? (fertility)
Explain as best you can
Sexual function
Complete loss
Partial loss
Other
Other
Mental Health Effect (sexual function)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Why other? (sexual function)
Explain as best you can
Pain
Mild
Moderate
Severe
Other
Other
Frequency (pain) (7 days)
Few days
Most days
Almost every day
Other
Other
Pain where?
Back
Neck
Legs
Hips
Feet
Hands
Other
Other
Mental Health Effect (pain)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Breathing Severity
Mild
Moderate
Severe
Other
Other
Frequency (breathing) (7 days)
Few days
Most days
Almost every day
Other
Other
Mental Health Effect (breathing)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Incomplete
Vertebrae?
T1 -12
L1-L5
S1-S5
Other
Other
Loss/Pain (multi-select)
Loss of or altered sensation, including the ability to feel heat, cold and touch
Loss of bowel or bladder control
Exaggerated reflex activities or spasms
Changes in fertility
Changes in sexual function, sexual sensitivity
Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
Difficulty breathing, coughing or clearing secretions from your lungs
Other
Other
Spasms
Sudden, involuntary jerking when bending (chest, back)
Sudden, involuntary jerking when extending (straightening)
Hyperactive (overactive) reflexes, such as a muscle spasm when you are lightly touched
Stiff or tight muscles at rest, so that it is difficult to relax or stretch your muscles
Muscle tightness during activity, making it difficult for you to control your movement.
Other
Other
Fertility
Can have children
Cannot have children
Other
Other
Mental Health Effects (fertility)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Why other? (fertility)
Explain as best you can
Sexual function
Complete loss
Partial loss
Other
Other
Mental Health Effect (sexual function)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Why other? (sexual function)
Explain as best you can
Pain
Mild
Moderate
Severe
Other
Other
Frequency (pain) (7 days)
Few days
Most days
Almost every day
Other
Other
Pain where?
Back
Neck
Legs
Hips
Feet
Hands
Other
Other
Mental Health Effect (pain)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Breathing Severity
Mild
Moderate
Severe
Other
Other
Frequency (breathing) (7 days)
Few days
Most days
Almost every day
Other
Other
Mental Health Effect (breathing)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Paraplegia
Vertebrae?
T1 -12
L1-L5
S1-S5
Other
Other
Loss/Pain (multi-select)
Loss of or altered sensation, including the ability to feel heat, cold and touch
Loss of bowel or bladder control
Exaggerated reflex activities or spasms
Changes in fertility
Changes in sexual function, sexual sensitivity
Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
Difficulty breathing, coughing or clearing secretions from your lungs
Other
Other
Spasms
Sudden, involuntary jerking when bending (chest, back)
Sudden, involuntary jerking when extending (straightening)
Hyperactive (overactive) reflexes, such as a muscle spasm when you are lightly touched
Stiff or tight muscles at rest, so that it is difficult to relax or stretch your muscles
Muscle tightness during activity, making it difficult for you to control your movement.
Other
Other
Fertility
Can have children
Cannot have children
Other
Other
Mental Health Effects (fertility)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Why other? (fertility)
Explain as best you can
Sexual function
Complete loss
Partial loss
Other
Other
Mental Health Effect (sexual function)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Why other? (sexual function)
Explain as best you can
Pain
Mild
Moderate
Severe
Other
Other
Frequency (pain) (7 days)
Few days
Most days
Almost every day
Other
Other
Pain where?
Back
Neck
Legs
Hips
Feet
Hands
Other
Other
Mental Health Effect (pain)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Breathing Severity
Mild
Moderate
Severe
Other
Other
Frequency (breathing) (7 days)
Few days
Most days
Almost every day
Other
Other
Mental Health Effect (breathing)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
How SCI?
Due to?
Health problem
Injury
Medical negligence
Other
Other
Health Problem
Brief details of which health problem & how it led to an SCI
What Injury
Road traffic accident
Work related injury
Sports activity
Personal inury
Violent attack
Accident
Other
Other
How did the injury happen?
Brief details
Due to?
Routine planned operation
Complications within operation
Malpractice by surgeon
Other
Other
Legal proceedings?
None
Engaged solicitor exploring
Ongoing court case
Going to court within 12 months
Other
Other
How did the injury happen? (other)
Brief details
What year did you have your SCI?
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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