Section 1 - Your Contact Details
Date of Birth
Section 2 - About You
1. Please say what causes your problems. What medical condition or disability do you have?
2. When you walk do you find that you limp or have any problem with balance? Do you stumble on kerbs? Have you fallen? If you have fallen when was the last time you fell?
3. How far can you walk, in yards, before you FIRST get pain or breathlessness? If you are not sure, tell us how many houses up the street in which you live you can manage before you get pain or breathlessness.
4. Do you need to rest after walking? If so roughly how long do you rest?
5. Do you have any panic attacks or become anxious when out of doors? How often?
6. Do you ever go out alone? If YES, where do you go?
7. If someone goes with you when you go out what do they do to help you?
8. Tell us if have you ever had a fall. This means actually hitting the floor, not stumbling. Does this happen suddenly or can you do anything to stop it?
9. Tell us how many falls you have had in the last three months.
10. Tell us if you have blackouts or fits. By blackout we mean actually losing consciousness. Does this happen suddenly or can you do anything to stop it?
11. Tell us how many blackouts or fits you have had in the last three months.
12. Tell us if you are forgetful or confused. By this we mean doing things like leaving the cooker on or not locking your doors at night.
13. Do you need anyone to encourage you to get up in the mornings, to change your clothes, to wash regularly, to make a meal, to eat regularly or to take any medication that you have?
14. Do you find that you are short-tempered? Are you aggressive with people you know?
15. Are you able to answer the telephone or deal with your household bills?
16. Do you go out socially? If not why not?
17. Do you watch TV or read? If so are you able to keep up with the TV programme? If you read do you find you have to keep reading the same part of the book time and time again?
18. Do you have panic attacks during the day? If so what causes you to panic? How often do these happen? How long do they last?
19. Do you have disturbed sleep? Do you have nightmares or panic attacks during the night? If so how many nights a week could this happen?
20. Do you prefer to be on your own?
21. Have you had any “accidents” where you perhaps left the cooker on or forgot to turn taps off? If so could you please tell us about these incidents?
22. Can you be bothered to cook a simple meal for yourself?
23. Do you harm yourself or have thoughts about doing this?
24. Please tell us about any aids or equipment you use e.g. walking stick, commode, walking frame, bath seat or special cutlery and where you got these from:
25. Do you work? If so is this full-time or part-time? Please tell us about your job and any problems with your job.
In the following table please tick any activities that you struggle with or find difficult. If doing the activity causes pain, distress, shortness of breath or tiredness please tick the box.
Getting out of bed
Getting into of bed
Getting comfortable in bed, turning in bed
Getting in or out of the bath
Washing or drying myself during and after a shower
Getting lids off bottles or jars
Putting on socks and shoes
Fastening buttons or zips
Getting on and off the toilet
Wiping after using the toilet
Getting to the toilet during the night
Planning a simple cooked meal
Peeling or chopping potatoes or carrots
Cutting up cooked food
Going up or downstairs
Getting up from a chair
Coping with night sweats