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I identify as
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Gender
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How did you find out about Polio NZ Inc?
Pamphlet from Medical Centre
Other
I contracted Polio in (year)
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At the age of
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While living in (town/country)
I received ‘treatment’ at:
Duncan Hospital Silverstream
Duncan Hospital Whanganui
Wilson Home Auckland
Public Hospital
Outside New Zealand
No formal treatment
Other
I was isolated for (days/weeks)
I was isolated at (name of public hospital or other facility/or at home)
I was removed from my family home for (days/weeks/years)
Areas of body permanently affected:
Spine
Left - half arm
Left - whole arm
Right - half arm
Right - whole arm
Left - half leg
Left - whole leg
Right - half leg
Right - whole leg
Both legs
Trunk of body
Breathing
Speech
Swallowing
Bladder
Bowel
No obvious damage at the time
Other
Orthotics now used:
Assistive breathing device
Back brace
Left ankle AFO
Modified shoes or shoe inserts
Neck brace
Right ankle AFO
Left leg full caliper
Left leg caliper below knee only
Right leg full caliper
Right leg caliper below knee only
Mobility aids currently used:
Walking stick(s)
Underarm crutches
Forearm crutches
Walker front of body
Walker surround body
Manual wheelchair
Electric wheelchair
Electric scooter
I am no longer able to stand
I require a hoist
I am living in a residential care facility
Have you been provided orthotics that you do not use because they are unsuitable?
Yes
No
Any comments?
Have you ever had surgery related to having had polio?
Yes
No
Any comments?
Are you currently being recommended surgery for any reason?
Yes
No
Any comments?
Do you have scoliosis?
Yes
No
Any comments?
Do you have Hyper-extending knees?
Yes
No
Any comments?
Have you ever had rotator-cuff injury?
Yes
No
Any comments?
Does your GP understand the late effects of polio?
Yes
No
Any comments?
Which DHB are you presently living within?
Auckland
Bay of Plenty
Canterbury
Capital and Coast
Hawkes Bay
Hutt Valley
Lakes
Nelson-Marlborough
Northland
South Canterbury
Southern
Tairawhiti
Taranaki
Waikato
Wairarapa
Waitemata
West Coast
Whanganui
What is your current living situation
Living alone
Living with family/partner
Receive in-home support services
Own home
Renting
Resthome/Hospital
Please pass my contact details to the local support group coordinator
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