Application form: Multiple Sclerosis

Application form: Multiple Sclerosis
This form can be completed by the applicant, relative, friend or professional.

The application form will give the conductors an overview of your condition and how it impacts on you. Please answer as many questions as you feel able, as this will help to ensure that the initial consultation is meaningful.

If you have any concerns about some questions or feel that you are not able to answer them please leave them blank.
Name

First NameLast Name
Email
example@example.com
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Present/previous occupation
If retired, please give date of retirement

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Year of diagnosis
MEDICAL INFORMATION
Which side of your body has been more affected?
Do you have stiffness?
Do you have paralysis?
Do you have tremor?
Is your vision affected?
Relevant medication, dosages and timings
Additional medical/surgical information (e.g. high blood pressure, arthritis, joint replacements, accidents)
Do you experience pain? If yes, where do you feel it?
How much does this pain restrict your daily activity?
IMPACT OF YOUR CONDITION

We appreciate that each day may be different, but to help us understand how your condition affects your life please answer the following questions as best you can.
Do you use aids to assist with moving around indoors? If yes, please state which aids.
Do you use aids to assist with moving around outdoors? If yes, please state which aids.
How much does fatigue impact on your daily life?

Do you?

Rows	Not at all	With help	On your own with difficulty	On your own easily
Walk around outside
Climb stairs
Get in and out of a car
Walk over uneven ground
Cross roads
Travel on public transport
Manage to feed yourself
Manage to make yourself a hot drink
Take hot drinks from one room to another
Do the washing up
Make yourself a hot snack
Manage your own money when you are out
Wash small items of clothing
Do your own hosework
Do your own shopping
Do a full clothes wash
Read newspapers or books
Use the telephone
Write letters or use a computer
Go out socially
Manage your own garden
Drive a car

The following questions are taken from an approved questionnaire for people with Multiple Sclerosis (MSQOL-54). We have chosen these as an appropriate tool to help us prepare for your initial consultation.

How often during the past month...

Rows	All the time	Most of the time	A good deal of the time	Some of the time	A little of the time	None of the time
Have you had difficulty concentrating and thinking
Did you have trouble keeping your attention on an activity for long
Have you had trouble with your memory
Have others, such as family members or friends, noticed that you have trouble with your memory or concentration
Did you feel full of pep
Have you been a very nervous person
Have you felt so down in the dumps that nothing could cheer you up
Have you felt peaceful and calm
Did you have a lot of energy
Have you felt downhearted and blue
Did you feel worn out
Have you been a happy person
Did you feel tired
Did you feel rested on waking in the morning

Do you have any problems with bladder continence?
Do you use a catheter?
Do you have problems with bowel continence?
Where do you feel you are at the moment. 0 - No quality of life. 10 - Full quality of life.
Could you please state where you heard about Conductive Education?
If you have attended Conductive Education in the past could you please give the dates and place.
Do you belong to a local branch of the Multiple Sclerosis Society or similar organisation? If yes, please state which.
Additional details
Do you have access to a computer, iPad or tablet?
Which one of these services would you be interested in?
GP Details

In exceptional circumstances we may wish to contact your GP or consultant. We will NOT contact them without discussing this with you first.
Name of GP

First NameLast Name
Address of GP

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name and Hospital of Consultant
How frequently do you see your consultant?
Any other relevant medical information you feel it is important for us to know?
I agree that I have disclosed all relevant medical information to the conductors at the National Institute of Conductive Education, Birmingham.I understand that it is my duty to inform them immediately of any relevant changes in my condition or medication and agree to do so.I agree that conductors may contact my GP or specialist should any further information be required. They will inform me of this and provide me with a copy if requested.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Application form: Multiple Sclerosis

MEDICAL INFORMATION

IMPACT OF YOUR CONDITION

Additional details

GP Details