Stroke Network
Member Story Questionnaire (Survivors)
Last revised: Jan. 24, 2013
Every stroke is different, all outcomes are different, and the approaches to healing vary. Member Stories are a way for Stroke Network members to share their: experiences, “recovery lessons” (or post-stroke perspectives) and post-stroke accomplishments (no matter how large or small).
Please fill out the following questions for your Member Stories article. Answer only those questions that apply to you. Questions are divided into three sections: Your Life Before and After Stroke, Stroke Background, and Stroke Network membership information.
Thanks for taking the time to fill out this form.
Your Life Before and After Stroke
Please answer these questions and provide any other comments or details that you feel would help make your story more interesting, more compelling, etc. The body of your Member Story will be written using the answers to these questions.
· What was your job / profession / career at the time of your stroke?
·
· What was the most difficult thing for you to deal with / come to terms with:
> the first few months after your stroke?
> at this time?Who or what has been critical in helping you get your life back (OR, in establishing your “new normal” life)?
· What has been your greatest achievement since your stroke?
· What has been the role of spouse, children, grandkids, friends or pets in your on-going recovery?
· How do you use your time since your stroke?
o Career wise, did you:
> go back to your old job?
> get a different job?
> cut back hours?
> volunteer/
o In other areas of your life:
> What special activities / interests / hobbies do you participate in?
> What special physical exercises or physical activities do you do now?
· Have you set any unusual / challenging goals for yourself? OR Have you accomplished any unusual / challenging goals?
· How has your stroke changed your outlook OR changed who you are?
· Do you network with other stroke survivors on a regular basis?
· If so, how do you network with survivors (on-line, in person, etc.) and how often?
· Please tell us anything else that you would like to share:
Personal
· Are you married? For how long?
· Do you have children and/or grandkids? How many?
· Do you have any pets? If so, how many and what kind?
Stroke Background
Your Stroke
· What was the month and year of your stroke?
· How old were you?
· What type of stroke did you have (ischemic or hemorrhagic)?
· Where in your brain was the stroke located?
· Where were you when you had your stroke?
· What were you doing at the time?
Your Post-Stroke Treatments
· Were you in an acute care hospital? Where? How long?
· Were you in a rehab hospital? Where? How long?
· Did you have out-patient therapy? Where? How long?
· Which of these traditional therapies did you participate in?
> Physical
> Occupational
> Speech
> Balance
> Other (please describe)
· Have you used any special medical equipment such as an AFO, Neuromove™, AutoMove brand therapeutic device, or other equipment (please describe)?
· Which of these non-traditional therapies did you participate in?
> Acupuncture
> Massage
> Feldenkrais
> Tai chi
> Yoga
> Therapeutic touch
> Hippotherapy
> Hyperbaric Oxygen Therapy
> Botox
> Constraint Therapy
> Speech software
> Computer games
> Water therapy
> Pet therapy
> Other (please describe)
· Which of these problems / “residuals” do you still have?
> Trouble speaking
> Trouble understanding language
> Trouble writing
> Paralysis (what part / parts of body?)
> Trouble swallowing, breathing
> Physical pain (specify where)
> Concentration
> Balance
> Anger
> Depression
> Fear
> Denial
> Other problem (please describe)
Stroke Network membership
· To verify your membership, please provide your Stroke Network userid.
· Do you have another email address, than the one where you are sending this from? If so, please tell us what it is.