Family & Carer Questionnaire
This short questionnaire helps us understand your child's needs, your family situation, and what matters most to you. Your answers help us tailor information and support - there are no right or wrong answers. This is not a clinical assessment and does not replace your therapist's role.
Name:
Home postcode:
Email address:
example@example.com
Phone number:
-
Area Code
Phone Number
Relationship to the person using the chair:
Parent
Carer
Family Member
Other
SECTION 1: ABOUT YOUR CHILD/YOUNG ADULT
Age range:
Under 5
5-11
12-18
18 +
How would you describe their mobility?
Full time wheelchair user
Uses a wheelchair most of the time
Uses a wheelchair for longer distances
Mobility varies day to day
Are there any changes happening now or expected soon? (tick all that apply)
Growth spurt
Recent surgery or recovery
Changes in posture or comfort
Starting or changing school/college
No major changes at the moment
SECTION 2: POSTURE & COMFORT
Which areas are currently most important to support? (tick all that apply)
Head and neck
Trunk/core
Hips and pelvis
Legs and feet
Overall positioning and comfort
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Chunc Limited | Unit 416, Tarsmill Court, Rotherwas Industrial Estate, Hereford, Herefordshire | HR2 6JZ | Telephone: +44 (0)1432 377512 | E-mail: info@chunc.co.uk | Website: www.chunc.com
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Are any of these becoming more noticable or difficult? (tick all that apply)
Comfort over long periods
Fatigue
Pressure or skin issues
Difficulty maintaining posture
No major concerns at present
SECTION 3: DAILY LIFE & ENVIRONMENT
Where is the wheelchair used most? (tick all that apply)
Home
School/college
Outdoors
Transport
Social activities
What matters most to your family day to day? (choose up to 3)
Comfort & safety
Independence
Ease of handling for carers
Ability to grow & adapt
Reliability & durability
Appearance/discretion
SECTION 4: EXPERIENCE & CONFIDENCE
How are things feeling overall?
Managing well
Some challenges
Increasing difficulties
Feeling overwhelmed
How confident do you feel managing wheelchair related decisions?
Very confident
Fairy confident
Unsure
Overwhelmed
What has your past experience been like? (tick all that apply)
Very positive
Mixed
Delays or not quite right
Excellent support
SECTION 5: REVIEW & TIMING
Has a wheelchair review been discussed recently?
Yes-review planned
Yes-no date yet
Not yet discussed
Not sure
When do you feel a review might be helpful?
Now/urgent
Within 6 months
6-12 months
Just gathering information
How urgent does support feel right now?
Everything feels stable
Some concerns but manageable
Challenges are increasing
We need support now
2
Chunc Limited | Unit 416, Tarsmill Court, Rotherwas Industrial Estate, Hereford, Herefordshire | HR2 6JZ |
Telephone: +44 (0)1432 377512 | E-mail: info@chunc.co.uk | Website: www.chunc.com
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SECTION 6: DECISION MAKING
Who is usually involved in decisions? (tick all that apply)
NHS therapist
Private therapist
Parent/carer
Young person themselves
School or college staff
What helps you feel confident making decisions? (tick all that apply)
Clear explanations
Seeing and trying equipment
Knowing timescales
Understanding long-term value
Hearing from other families
SECTION 7: SUPPORT PREFERENCES
How would you like us to suport you? (if at all)
General information only
Support for therapist discussions
Practical guidance and checklists
No further contact
How would you prefer to hear from us?
Email
Phone
Only when I contact you
SECTION 8: ANYTHING ELSE
Is there anything else you'd like us to know about your situation?
Thank you for completing this form.
Thank you for sharing this information. We'll use your anwers to tailor information or support that fits your needs, whether thats simple guidance or help with the next steps, now or in the future.
Family_Questionnaire_v1_04-2026
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Chunc Limited | Unit 416, Tarsmill Court, Rotherwas Industrial Estate, Hereford, Herefordshire | HR2 6JZ | Telephone: +44 (0)1432 377512 | E-mail: info@chunc.co.uk | Website: www.chunc.com
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