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Adult Membership Form

Please fill in this form in order to become a Adult Member of HemiHelp.

About you

Title:

First name: *

Surname: *

Date of birth

Are you male or female?:

Male

Female

What is your ethnic origin?:

This is an optional question to help our statistical understanding of the incidence of hemiplegia within different ethnic groups.

What is your main language?:

Contact details

Address: *

Postcode: *

Phone number:

Mobile number:

Email address:

Living arrangements:

With parents / family

Supported living

With partner

Independent

Other

Medical information

Which side is affected by hemiplegia?:

Left

Right

Do you think your hemiplegia is::

Mild

Moderate

Severe

Have you always had hemiplegia?:

Yes

Unsure

If no, how did you acquire hemiplegia?:

How old were you when diagnosed?:

Are you receiving any of the following treatment?:

Physiotherapy

Speech therapy

Occupational therapy

Other

Have you had any operations in relation to your hemiplegia? If so, please give details:

Do you attend a hospital or Development Centre?:

Yes

Do you have any other difficulties such as epilepsy, visual perception, speech? If so please state:

Education

Do you attend, or have you ever attended, any of the following?:

6th Form College

Further Education College

University

Employment

If you are now or have been employed, please tell us about the type of work you did. If you are seeking employment, what kind?:

Do you hold a driving licence?:

Yes

Hobbies and interests

Please list any hobbies or interests that you have:

Declaration

Please enrol me as an Adult Member of HemiHelp.: *

By becoming a member of HemiHelp I understand and accept that this CONFIDENTIAL information will be held on computer under the rules of the Data Protection Act and will be for the exclusive use of HemiHelp, who undertake not to disclose this information to any other organisations without my prior written consent.

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