Registration Neurological Conditions

Registration Form for Neurological Conditions.

Welcome. To help us to assess your individual needs and provide you with the most appropriate and suitable therapies we need you to provide some personal and health related information. Thank you. (The information you provide is processed by Compass staff only: securely and safely stored in Compass Client database and Therapy booking system). Oxygen Therapy is open to adults and young people over the age of 13.
Date

DayMonthYear
Date
Your Personal Details
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Gender
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Do you use a walking/mobility aid?
Living Status
Next of Kin/Emergency Contact Name
Emergency Contact Phone Number

Area CodePhone Number
Relationship to you
How did you hear about Compass?

Health Professional (GP, Physiotherapist etc)Poster in GP surgerySocial MediaSearch EngineWord of Mouth

Medical Information
Your GP Surgery/Medical Centre Name?
Medical Centre Address

Street Address

Street Address Line 2

CityState / Province

PostCode
Your main GP?
GP Phone Number

Area CodePhone Number
CHI Number (If Known)
Are you currently seeing a Specialist Consultant for your condition?
Clinic/Hospital?
Have you discussed coming to Compass with your Consultant?
If you are coming for Oxygen Therapy - were they supportive of you trying it?
Which Services are you interested in?
Oxygen Therapy
Physiotherapy
Rehabilitation
Group Classes
Complementary Therapies
Which Services are you interested in?*

Oxygen TherapyPhysiotherapy OR RehabilitationGroup ClassesComplementary Therapies

Signature Page
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

MonthDayYear
Date
Registration automatically enrols you as a member of Compass. This will mean that you can vote at our AGM and will receive Member Updates. To opt out please tick below.

I do not wish to become a Member
In accordance with the General Data Protection Regulation 2018, all personal, health and/or medical information (data) supplied to Compass 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 Compass, then please contact the Data Controller as detailed below.
Contact Details:
Data Controller, Genevieve Harrison
Compass
40c Swanfield
Edinburgh
EH6 5RX
T: 0131 554 5384
Email: genevieve@wearecompass.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?

	Yes, Limited a Lot	Yes, Limited a Little	No, Not Limited at all
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
Lifting or carrying groceries
Climbing several flights of stairs
Climbing one flight of stairs
Bending, kneeling, or stooping
Walking more than a mile
Walking several streets
Walking one street
Bathing or dressing yourself

	Yes	No
Cut down the amount of time you spent on work or other activities
Accomplished less than you would like
Were limited in the kind of work or other activities
Had difficulty performing the work or other activities (for example, it took extra effort)

	Yes	No
Cut down the amount of time you spent on work or other activities
Accomplished less than you would like
Didn't do work or other activities as carefully as usual

Registration Form for Neurological Conditions.

	All of the time	Most of the time	A good Bit of the Time	Some of the time	A little bit of the time	None of the Time
Have you been a very nervous person?
Have you felt so down that nothing could cheer you up?
Have you felt calm and peaceful?
Did you have a lot of energy?
Did you feel worn out?
Have you been a happy person?
Did you feel tired?