Spinal Outpatient Questionnaire
Please complete all fields
Clinician introduction and ID verification
Name
Role
ID Verification
The object of this form is to improve how we manage and monitor your health and improve your annual review. The information on this form will be held as part of your medical record. Do you consent to this?
*
Yes
No
Thank you. Your data has not been stored and no further information will be requested.
Patient Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Of Birth
*
-
Day
-
Month
Year
Date
MRN
NHS Number
*
Phone Number
-
Area Code
Phone Number
Alternative Phone Number
-
Area Code
Phone Number
Email
example@example.com
ID check
Photo ID
Date of Birth
Address Details
Full Name
Other
Name of person filling in form (and relationship if not the patient)
*
Are other people present during this consultation
Yes
No
Name and role
Agreed alternative communication choices if main call fails
Clinician reattempts connection
Clinician calls provided number
Clinician calls alternative number
Appointment is rescheduled, with written confirmation
Other
Consultant
*
Mr Ahmed
Mr Belci
Dr Graham
Dr Naidoo
Mr Swarna
Dr Hariharan
Other
Spinal Cord Injury and history
*
Medical History / Recent interventions
Current Mobility (Select all that apply)
*
Powered Chair
Manual Chair
Walking with aids (indoors)
Walking with aids (outdoors)
Independent
Other
Respiratory
Do you require ventilatory support at any time? (including cough assist or nebulisers)
Yes
No
In what way?
Have your ventilatory needs changed in the past year?
Yes
No
In what way?
Additional comments
Autonomic Dysreflexia
Do you experience autonomic dysreflexia?
Yes
No
Have you suffered any epsiodes in the past 12 months?
Yes
No
What do you feel are triggers?
Problems with bladder management
Problems with bowel management
Skin (infection, ingrowing toenails, pressure areas)
Other
Do you have an AD plan and medication?
Yes
No
Additional Comments
Bladder Management
Bladder management type (select all that apply)
Indwelling Catheter
Suprapubic Catheter
Intermittent Catheter
Sheath Drainage
Tap and Express / Straining
Flip Flow Valve
Independent / Voluntary
Other
Frequency of emptying
Fluid intake per day (litres)
Is bladder management negatively affecting your daily activities
Yes
No
On a scale from 1-5 how is bladder management negatively affecting your daily routine?
1
2
3
4
5
In which way?
Issues or recent changes (Haematuria, frequent catheter blockages, recurrent infections, continence, control, time to empty)
Have you had the following bladder investigations in the last 3 years?
Renal tract ultrasound
Bladder Ultrasound
Abdominal X-Ray
Renal Tract CT
Mag 3 renogram
Urogram
GP blood test for kidney function
None
Don't know
Additional Comments
Bowel Management
How do you currently manage your bowels?
Frequency?
Is bowel management negatively affecting your daily activities?
Yes
No
On a scale from 1-5 how is bowel management negatively affecting your daily routine?
1
2
3
4
5
In which way?
Issues or recent changes (continence, control, time to empty, bleeding, changes in requirements for medication)
Have you had any gastrointestinal investigations recently?
Yes
No
What and what was the outcome?
Additional Comments
Skin
Do you currently have any skin issues? (pressure sores, ulcers, non-healing cuts etc)
Yes
No
In which way?
How frequently is your skin inspected?
By whom?
Transfer technique
Lying to Sitting Ability
Rolling Ability
Upload images
Browse Files
Cancel
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Additional Comments
Neurological Function
Have you noticed an objective change in neurological function?
Yes
No
What symptoms has this given you?
Have you noticed any change in pain?
Yes
No
What symptoms has this given you?
Have you had any falls or changes in balance?
Yes
No
In what way?
Have you had any spasms?
Yes
No
In what way? How do they effect you?
Have you noticed any change in fatigue?
Yes
No
In what way? How has this effected you?
Additional Comments
Function and Daily Activities
Have you noticed any reduction in the following area?
Up and carrying out domestic tasks
Personal hygeine and dressing (with or without support)
Preparing and eating food
Social and work interactions
Activities and intimacy
None
Other
In what way? (eg loss of hand function, pain, change in care team etc)
Upper limb function: Muscle power, range, splinting, spasticity, oedema
Lower limb function: Muscle power, splinting, spasticity, oedema
Standing / Gait: Devices, time, distance, assistance, location
What is your current care package?
Has this changed in the past 12 months?
Yes
No
In which way?
Additional Comments
Mood / Support
Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?
Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?
Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless?
Not at all
Several days
More than half the days
Nearly every day
Community support: Family, friends, partner, social
Other
Current Medications
Any other information or support to be discussed
Conclusions and sign off
Next Steps
Referral to other team (internal)
Referral to other team (external)
Imaging request
Medication change
No Action
Other
Investigation request and reason
Next clinical contact
Teleconsultation
Video Consultation
Face to face review
Other team
When?
Have you covered:
Re-confirm discussion points as recorded
Patient has had the opportunity to ask questions
All information is recorded
Re-iterate next steps
Formal end of call
Hang up call
Other
Submit
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