This questionnaire will help us to determine whether Functional Electrical Stimulation (FES) may be an option for you and the appropriate type of program.All responses will be kept strictly confidential by the researchers.

(1) Background Information

Age:

(Years)
Sex:
Date of Injury:

(Use format 07 JAN 1999)
Level of Injury:

Cause of Injury:

Where did you learn about this questionnaire?:

(2) Please answer the following questions

Do you have:

a. Good general health?
b. History of autonomic dysreflexia?
c. Any movement below the level of your injury?
d. Any sensation (including pain) below the level of your injury?
e. Muscle spasms?
f. History of spontaneous lower limb fractures?
g. History of pressure sores?
h. Adequate hand and finger function to manipulate small objects?
i. Shoulder problems?
j. Normal range of hip, knee and ankle movement?
k. Ability to transfer independently?
l. Good physical fitness?
m. Any voluntary bladder control or sensation of fullness?
n. Prior bladder surgery?
o. Prepared to undergo surgery for implantation of stimulator and electrodes?
p. Motivation and time to participate in a research/training program?

Comments:

(3) Contact Details

If you would like to be contacted by one of the researchers regarding your suitability for an FES project, please provide your name and phone number in the space below.

Name:

Phone number:

Country:

Email address: