Application form: Stroke

Application form: Stroke
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
Email
example@example.com
Full name

First NameLast Name
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
Date of stroke

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical information
Which side of your body has been more affected?
Has your speech been affected?
Has your vision been affected?
Has your hearing been 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.

The following questions relate generally to your activities of daily living. Please tick the appropriate box.
Do you get about outdoors?
If you use a stick or a frame please state which
Do you move from bed to chair
Do you go up and down the stairs
If you have help please state which
Do you get dressed
In the bath or shower, do you
Do you use the toilet or commode
Do you wash your face, brush your hair and teeth (shave)
Do you feed yourself?
Are you incontinent of urine?
Are you incontinent of your bowels?
The following questions relate to how you feel your stroke has affected you and your quality of life.

In the past week, how would you rate the strenght of your...

Rows	No strenght	A little strenght	Some strenght	Quite a bit of strenght	A lot of strenght
Arm that was most affected by your stroke
Grip of your hand that was most affected by your stroke
Leg that was most affected by your stroke
Foot/ankle that was most affected by your stroke

In the past week, how difficult was it for you to...

Rows	Extremely difficult	Very difficult	Somewhat difficult	A little difficult	Not difficult at all
Remember things that people just told you
Remember things that happened the day before
Remember to do things (e.g. keep a scheduled appointment)
Remember the day of the week
Concentrate
Think quickly
Solve everyday problems

In the past week, how often did you...

Rows	All of the time	Most of the time	Some of the time	A little of the time	None of the time
Feel sad
Feel that there is nobody close to you
Feel that you are a burden to others
Feel that you have nothing to look forward to
Blame yourself for mistakes you made
Enjoy things as much as ever
Feel quite nervous
Feel that life is worth living
Smile and laugh at least once a day

In the past week, how difficult was it to...

Rows	Extremely difficult	Very difficult	Somewhat difficult	A little difficult	Not difficult at all
Say the name of someone who was in front of you
Understand what was being said to you in a conversation
Reply to questions
Correctly name objects
Participate in a conversation with a group of people
Have a conversation on the telephone
Call another person on the telephone; including selecting the correct number and dialling

During the past 4 weeks, how much of your time have you been limited in...

Rows	None of the time	A little of the time	Some of the time	Most of the time	All of the time
Your work (paid, voluntary or other)
Your social activities
Quiet recreational activities (crafts, reading)
Active recreation (sports, outings, travel)
Your role as a family member and/or friend
Your participation in spiritual or religious activities
Your ability to control your life as you wish
Your ability to help others

On a scale from 1 to 10, how much have you recovered from yoru stroke?
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 Stroke Association or similar? 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?
Name of specialist nurse (if appropriate)
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: Stroke

Medical information

IMPACT OF YOUR CONDITION

ADDITIONAL DETAILS

GP Details