About you

About you

Your name:

Your name will not be stored anywhere. It will only be used to personalise your summary printout

Are you in education, in employment or both?

Your condition

About your condition

Would you say you have predominately right sided or left sided hemiplegia?

Which part of your body does your hemiplegia affect?

Does your hemiplegia mean you are affected by any of the following?This question is about the symptoms or effects of your hemiplegia. It includes associated and hidden conditions and/or effects. Choose as many as you feel apply. You can use the text box to make any additional notes that are relevant to your particular situation .

Physical effects

Cognitive effects

Emotional, behavioural or social issues

The support you need

Supportive technologies and devices

Do you currently use any of the following products to help you in school/work?

In education:

At work:

Support with activities

Do you want support with activities in any of the following areas?

In education:

At work:

In those areas, what particular changes could be made or steps be taken that would make it easier for you to be more independent?These should be discussed thoroughly with the relevant person, so that you can be sure you get the right support. Please use the text box to add any specific details you need to.

In education:

Moving around the building

Lessons

Exams

Sports

Making and maintaining friendships

Lunch and break times

Managing your time

At work:

Moving around the office

Tasks and projects

Working relationships

Lunch and break times at work

Managing your time at work

Questions and support

Asking questions

If someone has a question about your hemiplegia or support needs they should...

Which nominated person should they contact?

We will not save any names or personal details - they will only be used for your report

Emergencies

In case of emergency please contact:

This information will not be stored. It will just be used on your summary printout.

Your report

You're almost there!

In order to understand more about who finds this tool useful and to help us improve it for the future, we’d like to understand a little more about you and your circumstances. You don’t have to share this information with us, but it would be very helpful for us. This anonymous information will be stored securely and only used for internal monitoring purposes.

You can simply now if you prefer.

Some information about you

Who did you complete the checklist for?

How old are they?

How would you describe the amount of time it took you to complete the HemiCheck checklist?

Are you currently a HemiHelp member?Members receive our quarterly magazine

Are you willing to share your email address with us (so we might occasionally inform you of useful HemiHelp services or events)?

How old are you?

Are you male or female?

Where do you live?