* denotes a required field
1. Which neuromuscular condition affects you?
2.1 What is the age of the person affected by the condition?
0 - 5
6 - 10
11 - 15
16 - 20
21 - 25
26 - 30
31 - 35
36 - 40
41 - 45
46 - 50
51 - 55
56 - 50
51 - 55
56 - 60
61 - 65
65+
2.2 How old were you when you were affected by the condition?
0 - 5
6 - 10
11 - 15
16 - 20
21 - 25
26 - 30
31 - 35
36 - 40
41 - 45
46 - 50
51 - 55
56 - 50
51 - 55
56 - 60
61 - 65
65+
Undiagnosed
3. What was your experience of the diagnosis process (from the time symptoms began to confirmed diagnosis)?
Excellent
Good
Poor
Very Poor
Pease add any comments you may have about your experience of the diagnosis process
4. Where do you visit to receive specialist care for your condition?
How often do you receive specialist care for your condition?
Monthly/Bimonthly
Less than 2 months
2 - 6 months
6 months - 1 year
5.1 Do you have access to a specialist neuromuscular consultant (not a general neurologist)?
Yes
No
Don't know
Please add any other comments you may have about access to a specialist neuromuscular consultant
How do you rate the service the you receive from your consultant?
Excellent
Good
Poor
Very Poor
5.2 Do you see a physiotherapist?
Yes
No
N/A
If yes, does he / she understand your condition?
Yes
No
How is this funded?
NHS
Yourself
Charity
Other
Do you feel that you get enough physiotherapy?
Yes
No
Please add any other comments you may have about physiotherapy
How does physiotherapy benefit you?
5.3 Do you receive regular hydrotherapy in a hydrotherapy pool?
Ys
No
N/A
Please add any other comments you may have about hydrotherapy
If yes, where do you access this?
Home
Hospice
Hospital
School
Other
5.4 Do you see a specialist muscle nurse?
Yes
No
Don't know
If yes, how do you rate the service that you receive?
Excellent
Good
Poor
Very Poor
Please add any other comments you may have about your specialist muscle nurse
5.5 Do you see an occupational therapist?
Yes
No
N/A
If yes, does he / she understand your condition?
Yes
No
Have you experienced any delays in receiving an appointment with your OT?
Yes
No
Does he / she come to your home?
Yes
No
How do you rate the service that you receive?
Excellent
Good
Poor
Very Poor
Please add any comments you may have about occupational therapy
5.6 Do you see a speech and language therapist (SALT)?
Yes
No
N/A
If yes, does he / she understand your condition?
Yes
No
How do you rate the service that you receive?
Excellent
Good
Poor
Very Poor
Please add any comments you may have about speech and language therapy
5.7 Do you see a dietician?
Yes
No
N/A
If yes, does he / she understand your condition?
Yes
No
How do you rate the service that you receive?
Excellent
Good
Poor
Very Poor
Please add any comments you may have about your dietician
5.8 Do you have a key worker or care co-ordinator that you can contact?
Yes
No
Don't know
How do you rate the service that you receive?
Excellent
Good
Poor
Very Poor
Please any comments you may have about your key worker
6.1 Do you see a social worker?
Yes
No
If yes, is this your key worker / care co-ordinator?
Yes
No
How do you rate the service that you receive?
Excellent
Good
Poor
Very Poor
Please add any comments you may have about your social worker
6.2 Are you satisfied with the amount and clarity of information about the services that are available to you?
Yes
No
6.3 Are you satisfied with the level of emotional support for you and your family members?
Yes
No
7.1 Do you use a wheelchair? (If no please go to question 8)
Yes
No
7.2 How often do you use your wheelchair?
All the time
Outside the house
Only when travelling long distances
7.3 Which of the following describes your wheelchair?
Manuel
Powered
Electric
Hydraulic
7.4 How is this funded?
NHS
Yourself
Charity
Other
7.5 Have you experienced any delays or difficulties in receiving the appropriate chair?
Yes
No
Please add any other comments you may have on wheelchairs
How do you rate the service that you receive for assistance in the upkeep of your wheelchair?
Excellent
Good
Poor
Very poor
8. How was/is your experience of the transition from childhood to adult services?
Excellent
Good
Poor
Very poor
Please add any comment you may have on transition
9.1 What are your living arrangements?
Own own home
Live with parents
Rent from private landlord
Renting from the council
9.2 Has living with a neuromuscular condition affected your income or standard of living? (e.g. not being able to work, having to purchase equipment yourself, etc.)
Yes
No
Please add any comments you may have on living arrangements
9.3 How do you rate the support that you have received regarding living independently?
Excellent
Good
Poor
Very poor
Please add any other comments you may have on independent living
9.4 Have you experienced any delays or difficulties in receiving the appropriate home adaptations by your local authority?
Yes
No
Please add any comments you may have on home adaptations
9.5 If it is suitable, did you receive grant assistance for the maintenance of home adaptations?
Yes
No
10.1 If you are a carer / family member completing this survey on behalf of an individual, have you received a carer’s assessment?
Yes
No
Don't know
10.2 Do you have regular access to respite care? e.g. hospice, care home, etc.
Yes
No
11. Overall, how well does your carer feel his / her needs have been met?
Excellent
Good
Poor
Very poor
Please add any other comments you may have about carers
12. Have you experienced any delays in receiving timely health and social care?
Yes
No
Please add any comments you may have on health and social care
13. Are you in employment?
Yes
No
N/A
Full time
Part time
Volonteer
Home
If no, are you currently seeking employment?
Yes
No
Please add any other comments you may have about employment
14. Are you currently in education?
Yes
No
N/A
Primary Secondary
Post Secondary (College or University)
Please add any other comments you may have on education
15. Do you want to attend a local launch event for the report?
Yes
No
Address
Would you be willing for us to contact you to share your experiences
Yes
No
Are you happy for your comments to be published in the report?
Yes
Yes but anonymously
No
Please use this space to provide any additional information in support of this survey: