Bolton Neuro Voices Application Form

Part One: About You

Name

Male
Female

Date of birth

Neurological Diagnosis

Contact telephone number

Address

Street Address Address Line 2 Town/City Postcode

Email address

Enter Email Confirm Email

Preferred written contact:

Post
Email

Please tell us how you heard about this course

What do you want to achieve?

Please indicate your 3 priorities from the following list;

If you have ticked "other" above, please give a brief description below

Who is your emergency contact?

Name

Telephone number

Relationship to you

Part Two: About your health

It is important that we understand all of your needs and any health risks from your participation. Please tick if you have any of the following medical problems. Having one of these conditions will not necessarily exclude you, but we do need to know about it. If you are unsure of your answers, please discuss participating in hydrotherapy with your GP.

Please give details of any other condition the Physiotherapist should be aware of below

What is your height?

What is your weight?

Part Three: About Your Mobility

Standing

Able to stand independently for up to 10 minutes
Able to stand with aids or assistance
Unable to stand

Walking

Able to walk without aids or assistance 100 metres
Able to walk without aids or assistance up to 10 metres
Able to walk with aids or assistance 100 metres
Able to walk with aids or assistance up to 10 metres
Unable to walk

Part Four: Access and assistance

Please tick to indicate how much assistance you will require to get from changing room to pool side.

Independently walk without assistance
Independently walk or walk with a walking aid, but will need volunteer assistance to support you or carry items
Pool-provided wheelchair to poolside, access pool using steps
Pool-provided wheelchair to poolside and transfer to hoisting chair
Use ceiling tracking into pool

Please tick one box below

I confirm I am independent in dressing and undressing
I require assistance with dressing and undressing and will be bringing a carer with me

Part Five: About Your Water Confidence

I am nervous about being in the water
I am confident about being in the water

When was the last time you accessed a pool?

If you require assistance whilst in the water from your own carer, please give your carer’s details below. Ensuring their safety is also important and we will contact them direct.

Carer's name

Carer's contact number

Carer’s email address

Part Six: Follow-up appointments

The Physiotherapist will review your application form and will be following up with a telephone call, probably during week beginning 23rd September. If this is not convenient please indicate below the best time to call, and we will try to accommodate. Please note our normal working hours are 8am-6pm Monday to Thursday.

The best times to call are

If you would like someone else to complete your telephone assessment, please indicate below:

Name

Telephone Number

I consent to the physiotherapist discussing my condition with the person named above

BNV Application Form

Part One: About You

Part Two: About your health

Part Three: About Your Mobility

Part Four: Access and assistance

Part Five: About Your Water Confidence

Part Six: Follow-up appointments