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Contacting CHEME
WATCh-Ad Assessment Questionnaire
Consent
You must tick all boxes to continue
(If you are a carer, please complete this consent form on behalf of the person you care for)
I confirm that I have read the
WATCh-Ad Tool factsheet
(dated 08/03/2019) and I understand that the information I provide will be used to evaluate the outcomes of my new wheelchair.
I understand that the WATCh-Ad Tool will ask questions about my quality of life, wheelchair use and basic demographic information (such as gender and date of birth).
I understand that by completing the WATCh-Ad Tool I agree for any information I provide to be stored securely by Bangor University, and that only the WATCh-Ad team and my wheelchair provider will have access to this information.
I understand that by completing the WATCh-Ad Tool I consent for any information I provide to be used in future analysis and research. I understand that any identifiable information (i.e. name, email address) I provide will not be published or made available at any time.
I understand that completing the WATCh-Ad Tool is completely voluntary and that I am free to withdraw any information I provide at any time without giving a reason, and my health or social care will not be affected.
I agree to complete the WATCh-Ad tool.
Patient details
Name and/or Hospital ID number
Email
Date of Birth
Gender
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Other
Prefer not to say
Primary diagnosis / reason for wheelchair use
Wheelchair type(s)
Powered
Manual
Adapted pushchair
None
Level of need
Low
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Medium powered
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Specialist
Unknown
Name of Wheelchair service (if known)
Assessor details (if relevant)
Name
Email
