MSTC Registration Form

MSTC Registration Form

In order to access our Oxygen Therapy or Physio Sessions, we need you to provide us with some personal and health related information. This is important as it enables us to assess your individual needs and provide you with the most appropriate and suitable therapies. We have endeavoured to keep the information we request from you to the minimum necessary.
Date

Day Month Year
Date
Hour Minutes AM/PM Option
Are you registering for: *

Adult Child
IMPORTANT: The Parent/Guardian of children (under the age of 13 if appropriate) must complete this form in order to access our Support Services and Therapies. We need you to provide us with some personal and health related information. This is important as it enables us to assess your child’s individual needs and provide him/her with the most appropriate and suitable therapies. We have endeavoured to keep the information we request from you to the minimum necessary.
Have you attended the MS Therapy Centre before? *

Yes No
Which Services are you interested in? *

Oxygen Therapy Physiotherapy Online Classes

Accept & Agree Terms

We require your CONSENT for specific aspects of what we do, please READ and CHECK the appropriate box/es. Thank You
Client Signature *
Please Enter Your Full Name In Capitals
Date *

Month Day Year
Please verify that you are human *
In accordance with the General Data Protection Regulation 2018, all personal, health and/or medical information (data) supplied to the MS Therapy Centre Lothian will be held in the strictest confidence and will not be passed on to any third parties without your consent. Your personal, health and/or medical information (data) will only be used for the purposes as outlined on our Privacy Policy/Statement. If you have any concerns regarding the way your information is stored or used by MSTC Lothian, then please contact the Data Controller as detailed below.
Contact Details:
Data Controller, Nancy Campbell
The MS Therapy Centre Lothian
40c Swanfield
Edinburgh
EH6 5RX
T: 0131 554 5384
Email: nancy@mstc-lothian.org.uk
Further Information:
The Information Commissioner's Office - Scotland
45 Melville Street
Edinburgh
EH3 7HL
Telephone: 0303 123 1115
Email: Scotland@ico.org.uk
Should be Empty:

	No	Yes	If yes, please give details including dates.
Do you have emphysema?
Have you ever had tuberculosis?
Do you have Chronic Obstructive Pulmonary Disease?
Have you ever had any other lung problems?
Have you had any surgery in the last six months?
Do you have a cold, chest infection etc?
Do you suffer from chronic sinusitis?
Do you have a temperature or a fever?
Do you have Otosclerosis (bone growth of the middle ear)?
Have you ever had a rupture of the oval or round membrane of the inner ear?
Do you have optic neuritis?
Do you have glaucoma?
Do you have congenital spherocytosis (auto-hemolytic anemia- disease of the blood)?
Do you have a pacemaker or other medical devices?
Are you pregnant?
Do you suffer from any long term conditions? e.g. claustrophobia, diabetes, epilepsy
Are you or have you ever been a smoker?

	Not at all	A little	Moderately	Quite a bit	Extremely
Do physically demanding tasks?
Grip things tightly (e.g. turning on taps)?
Carry things?

	Not at all	A little	Moderately	Quite a bit	Extremely
Problems with your balance?
Difficulties moving about indoors?
Being clumsy?
Stiffness?
Heavy arms and/or legs?
Tremor of your arms or legs?
Spasms in your limbs?
Your body not doing what you want it to do?
Having to depend on others to do things for you?
Limitations in your social and leisure activities at home?
Being stuck at home more than you would like to be?
Difficulties using your hands in everyday tasks?
Having to cut down the amount of time you spent on work or other daily activities?
Problems using transport (e.g. car, bus, train, taxi, etc.)?
Taking longer to do things?
Difficulty doing things spontaneously (e.g. going out on the spur of the moment)?
Needing to go to the toilet urgently?
Feeling unwell?
Problems sleeping?
Feeling mentally fatigued?
Worries related to your MS?
Feeling anxious or tense?
Feeling irritable, impatient, or short tempered?
Problems concentrating?
Lack of confidence?
Feeling depressed?

Your Personal Information