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NAME
Your answer
Email Address
Your answer
HOME ADDRESS
Your answer
HOME PHONE
Your answer
MOBILE PHONE
Your answer
Emergency contact - Name
Your answer
Emergency contact - Phone
Your answer
BIRTH DATE
MM
/
DD
/
YYYY
Male
Female
Clear selection
Spinal cord injury
Spina bifida
Other:
Clear selection
DATE OF INJURY
MM
/
DD
/
YYYY
Yes
No
Clear selection
No
Yes, on the right side
Yes, on the left side
Yes, on both sides
Clear selection
DO YOU HAVE UPPER BODY IMPAIRMENT
Your answer
DO YOU HAVE LOWER BODY IMPAIRMENT
No
Yes, on the right side
Yes, on the left side
Yes, on both sides
Clear selection
If you do have lower limb impairment, please describe it in detail
Your answer
ARE YOU INDEPENDENTLY MOBILE
please note that you must ensure you have care support if you need it
Yes
No
Option 3
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WHAT DO YOU USE FOR MOBILITY
Manual wheelchair
Power wheelchair
Walking frame or similar
Walking stick
Crutches
No
Clear selection
Do you suffer from Seizures
Yes
No
Clear selection
If yes, when was your last seizure?
Your answer
If yes, how often do you have seaizures?
Your answer
Are you diabetic?
Yes
No
Clear selection
If yes, do you need assistance to monitor your blood sugar or to take insulin?
Yes
No
Clear selection
Please provide any other medical information that we need to know about?
Your answer
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