Profile questionnaire « Health »
Eye, ear, nose and throat disorders
Painful conditions or diseases of the bones/joints/muscles
Dental conditions
Allergies
Cancer
Diabetes
Skin disease
Heart/blood diseases
Digestive diseases
Immunological diseases
Neurological/cerebral diseases
Respiratory diseases
Weight problems
Women's health
Men's health
Mental health and behaviour
Sexual health
Learning and cognitive disorders (ADHD, ADD, etc.)
Sleep disorders
Post-traumatic disorder (loss of limb, accident, war, surgery, etc.)
None of the above
I do not wish to answer
Orthodontic appliances
Restraint systems
Crutches
Oxygen cylinders
Cane
Walker
Denture
Manual wheelchair
Motorised wheelchair
Multisport chair
Verticalizer
Lift chair
Raised Toilet seat
Angled and enlarged cutlery
Anti-slip lenses
Bath seat
Sock or stocking aid
Grab rail
Transfer turner/turning aid
Righting bar
Adapted car
Adapted keyboards, adapted mice, ergonomic office chairs, forearm supports, video magnifiers, software, speech synthesisers, voice dictation, etc.
Medical bed
Nicotine gum
Nicotine patches
Retainers
Inhalers
Adrenaline injector
Insulin pen injector
Blood glucose meter
Contact lenses
Glasses with corrective lenses
Reading glasses
Nebulisers
Prosthesis
Hearing aids
Hip prosthesis
Knee prosthesis
Dental prosthesis
Stents
Pacemakers
Other medical equipment, please specify :
None of the above
I do not wish to answer
Tinnitus
Impaired vision
Astigmatism
Cataract
Blindness
Conjunctivitis
Vision correction - laser treatment
Macular degeneration
Glaucoma
Hyperopia
Myopia
Nasal obstruction
Otitis
Hearing loss
Presbyopia
Snoring
Dry eye syndrome
Colour blindness
Hearing impairment of any kind
Other ear, nose or throat conditions, please specify
None of these disorders
I do not wish to answer
Mild impairment
Moderate impairment
Severe impairment
Profound impairment
Almost total impairment
Total impairment
I do not wish to answer
Braille (reading method for the visually impaired or blind)
Non-optical visual aids (memory telephones, large keys, line guides for cheques, etc.)
Optical vision aids (magnifiers, telescopic systems)
Electronic distance vision aids (helmets with an integrated video camera, displaying the image in front of the patient's eyes)
Coloured filters (to enhance contrast vision).
Speech synthesis: Android talkback or iOS voiceover
A white cane
A guide dog
Other, please specify
I do not wish to answer
Mild hearing loss: speech is difficult to understand in a noisy environment and soft sounds are not perceived. Tinnitus (continuous ringing or whistling) and hyperacusis (intolerance to certain frequencies and noises) may occur.
Moderate hearing loss: soft and moderately loud sounds are not audible and speech is very difficult to understand in the presence of ambient noise.
Severe hearing loss: group conversations are laborious and you have to speak loudly to be heard. These exchanges are a source of stress and cognitive fatigue for the hearing impaired person.
Profound hearing loss: communication is impossible without hearing aids, and only a few very loud sounds are perceived by the hearing impaired person.
I do not wish to answer
BTE and ITE hearing aids
Cochlear implant
Lip reading
British sign language
Speech therapy
Audio induction loop
Personal amplifier
Transmitter/receiver cases
Deaf / Hearing communication platform
Speech synthesis
Subtitles
Android and IOS applications
Velotype
Other, please specify
I do not wish to answer
Amputation
Arthritis
Rheumatoid arthritis
Osteoarthritis
Lower back pain
Muscle pain
Neuropathic pain
Persistent or chronic pain
Muscular dystrophy
Fibromyalgia
Gout
Joint inflammation
Lupus
Headaches
Migraines
Myasthenia gravis
Osteoporosis
Psoriatic arthritis
Multiple sclerosis
Other bone/joint/muscle pain or disease, please specify
None of these answers
I do not wish to answer
Abscess
Mouth ulcers
Bruxism
Cavities
Tooth loss
Gingivitis
Oral thrush
Periodontitis
Other dental condition, please specify
None of these answers
I do not wish to answer
Food allergies
Latex allergy
Allergies to cosmetics
Plant allergies (poison ivy, etc.)
Drug allergies
Seasonal allergies (pollen, etc.)
Insect bites
Other allergies, please specify
None of these answers
I do not wish to answer
Ovarian cancer
Uterine cancer
Prostate cancer
Bladder cancer
Bone cancer
Brain cancer
Cervical cancer
Colon cancer
Liver cancer
Lung cancer
Kidney cancer
Breast cancer
Leukaemia
Non-Hodgkin's lymphoma
Hodgkin's disease
Melanoma
Multiple myeloma
Other cancer, please specify
None of these answers
I do not wish to answer
I
II
I do not wish to answer
By mouth (tablets)
By injection: via an insulin pump
By injection: via a NON-connected insulin pen
By injection: via a connected insulin pen
Both injectable and oral
No
I do not wish to answer
Acne
Amyloidosis
Atopy
Carcinoma
Couperose
Dermatosclerosis
Eczema
Skin rash (dermatitis)
Moles/Warts
Mycoses
Dry skin
Psoriasis
Age spots
Other skin condition, specify
None of these answers
I do not wish to answer
Stroke/TIA
Anemia or other blood disorders
Angina pectoris
Heart attack/myocardial infarction
Pulmonary embolism
Atrial fibrillation
Congestive heart failure (CHF)
Haemophilia
Hepatitis A
Hepatitis B
Hepatitis C
Hyperlipidemia
Hypoglycaemia
Low blood pressure
Heart disease
Circulatory problems in the legs
Abnormal heart rhythm
High cholesterol
High triglyceride levels
High blood pressure/hypertension
Thrombosis
Deep Vein Thrombosis
Recent blood transfusion
Varicose veins
Other heart/blood disease, specify
None of these answers
I do not wish to answer
Inflammatory bowel disease (IBD)
Gallstones
Kidney stones
Colitis
Constipation (persistent or chronic)
Diarrhoea (persistent or chronic)
Gas/bloating
Bowel incontinence
Urinary incontinence/bladder control
Urinary tract infection (UTI)
Crohn's disease
Nausea
Pyrosis/GERD
Irritable bowel syndrome (IBS)
Stomach ulcers
Intestinal ulcers
Overactive bladder
Other gastrointestinal condition, specify
None of these answers
I do not wish to answer
Primary immunodeficiency (PI)
Lupus
HIV/AIDS
Other immunological disease, specify
No
I do not wish to answer
Cerebrovascular accident (CVA)
Seizure (not epilepsy-related)
Dementia
Alzheimer's disease
Parkinson's disease
Headaches
Migraines
Multiple sclerosis
Essential tremor
Epilepsy
Other brain/neurological condition, specify
None of these answers
I do not wish to answer
Asthma
COPD (chronic obstructive pulmonary disease)
Bronchitis (chronic)
Emphysema
Cystic Fibrosis
Pulmonary vascular disease
Chronic respiratory diseases
Chronic sinusitis
Other respiratory disorders, please specify
None of these answers
I do not wish to answer
Loss of libido
No menses (amenorrhoea)
Vaginal candidiasis
Prenatal supplement
Menstrual cramps (dysmenorrhoea)
Female sexual dysfunction
Endometriosis
Uterine fibroids
Vaginal infections
Menopause
Osteoporosis
Painful ovulation (Mittelschermz)
Abnormal uterine bleeding
Infertility
Pelvic inflammatory disease
Premenstrual syndrome
Hormone replacement therapy
Premenstrual dysphoric disorder
Female sterilisation
Other female health problem, please specify
None of these answers
I do not wish to answer
Loss of libido
Erectile dysfunction (impotence)
Sexual dysfunction
Low testosterone levels
Male infertility
Premature ejaculation (PE)
Testicular disorder
Penis disorder
Vasectomy
Other male conditions, please specify
None of these answers
I do not wish to answer
Anxiety
Stress-related anxiety
Bipolarity (manic-depressive disorder)
Anxiety attacks
Dementia
Persistent depressive disorder (dysthymia)
Seasonal affective disorder (SAD)
Depressive disorder (depression)
Alzheimer's disease
Phobias
Schizophrenia
Paranoia
Post-traumatic stress disorder (PTSD)
Addictive disorder
Eating disorders
Social anxiety disorder
Attention deficit disorder (ADHD, ADD)
Obsessive compulsive disorder (OCD)
Psychiatric disorders of any kind
Other mental and behavioural health problems, please specify
None of these answers
I do not wish to answer
Loss of libido
Sexual dysfunction
Herpes
Genital herpes
HIV/AIDS
Erectile dysfunction (impotence)
Sexually transmitted diseases (STDs) of any kind
Human papillomavirus (HPV)
Infertility
Other sexual health problem, please specify
None of these answers
I do not wish to answer
ADHD or ADD (Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder)
Autism, autistic spectrum disorders (Asperger's syndrome, pervasive developmental disorder)
Intellectual development disorders (IDD)
Dyslexia
Dysorthography
Dyscalculia
Dyspraxia (DCD)
Dysphasia
Intellectual disability
Speech, language and communication disorders
Tourette's disorder and other tics
Other cognitive and learning disabilities, please specify
None of these disorders
I do not wish to answer
The tutorial function, which uses the computer and its software as a kind of repeater, with batteries of systematic exercises.
The procedural function: IT is a vehicle for reflection and offers specific support to encourage reasoning and even to organise thought.
The communication function: encompasses the ability to consult and exchange resources.
The supplementary or prosthetic function: the computer becomes a tool capable of directly or indirectly replacing a deficient function 'doing when you can't.'
The augmentative function facilitates and optimises certain abilities that children already have, but to a lesser extent. In this case, the computer makes it possible to improve the efficiency of the pupils' productions and therefore to increase their performance, which without this aid would be less operational.
Speech synthesis
Spellcheckers
Voice recognition or voice dictation
Pulsed light lamp
Keyboard with dyslexia-friendly font
Digital pen
Reader and translator pen
Other, please specify
None of these
I do not wish to answer
Sleep apnoea
Insomnia
Narcolepsy
Sleepwalking
Restless legs syndrome
Other sleep disorder, specify
None of these answers
I do not wish to answer
Personal Independence Payment (PIP)
Attendance Allowance
Disability Living Allowance (DLA)
Carer’s Allowance
Employment and Support Allowance (ESA)
Blue Badge Scheme
Disabled Students’ Allowance (DSA)
Access to Work grant
None of these
I do not wish to answer
High level of support (Full-time care, more than 35 hours per week)
Moderate level of support (Between 20-35 hours per week)
Low level of support (Less than 20 hours per week)
I do not wish to answer
Yes
No
My application is in progress
I do not wish to answer