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Your Stroke Story

This questionnaire has been designed to gather as much information about your situation, which will help us to give you the most valuable information and guidance during our free call. After sending the completed questionnaire we will contact you by email to set up the free call or coaching session within a week.

Arjan and Linda

P.S. Privacy is very important for us. We never share any information with third parties or anyone for that matter. Everything you share remains strictly confident at all times.

P.P.S. We do not set up calls if the questionnaire has not been filled in (-;

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Question 1 of 14

Name and Surname:

Question 2 of 14

Email Address

Question 3 of 14

Mobile Telephone Number (including country code): 

Question 4 of 14

How many years ago was your stroke or brain injury?

A

Less then one year

B

1

C

2

D

3

E

4

F

5

G

6

H

7

I

More than 7 years ago

Question 5 of 14

Did you have one stroke?

A

Yes

B

No

C

New Choice

Question 6 of 14

Please tell us in a short what happened?

Question 7 of 14

Did they find out why you had the stroke?

A

Yes

B

No

Question 8 of 14

If Yes, can you please elaborate on this in a short paragraph?

Question 9 of 14

What is your biggest challenge at this moment?

A

Walking

B

Spasticity

C

Arm function

D

Hand function

E

Leg function

F

Foot

G

Speech

H

Cognition

I

Balance

J

Tiredness

K

Other

Question 10 of 14

Please provide additional relevant information that you think may add to the understanding of the previous question.

Question 11 of 14

Please describe briefly what therapies you have had so far, and indicate which therap(y)ies helped the most:

Question 12 of 14

What therapy are you following at present and how many hours a week?

Question 13 of 14

Please indicate what is the most important for you to change, and get better at this moment?

Question 14 of 14

Are you using medication at present and if so which medication(s)?

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