Active Neuro Registration

Active Neuro Registration

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About Active Nuero

Thank you for your interest in our Active Nuero programmes. This service was piloted in the Mid-West through funding from the SlainteCare Integration Fund and we are now delighted to continue that service and to expand to more areas. These programmes are now made possible by funding from the HSE through the Strategic Transformation Office, the Strengthening Disability Services Fund and through CHO-2 Disability services. They are available for people living with any neurological condition residing in Limerick, Clare, Tipperary, Galway, Mayo, Roscommon, Wicklow, Dun Laoghaire and South East Dublin. You do not need to be a member of MS Ireland to participate.

How does Active Neuro differ from the MS Ireland regional programmes?

MS Ireland provides general health-promoting exercise programmes to people living with MS. Active Neuro programmes cater to people living with any neurological condition

, for example, stroke, Parkinson's disease or ataxias. As there are symptoms in common across these conditions, this allows us to deliver more specialised and tailored programmes to a wider range of participants.

How is my information managed?

This form will help us learn about you and what you would like to gain from a programme. Your information is input directly into MS Ireland's SalesForce systems and is only available to the physiotherapy team that delivers Active Neuro. You can decide against integrating your information with MS Irelands membership database if you wish. However, to avoid unnecessary duplication within our database, your name, email and date of birth only will be visible to all MSIreland staff. If you are already a member of MS Ireland, your regional office will be able to see only that you are taking part in Active Neuro. They will not be able to see the information you enter.

To help us find the programme that best matches your needs, please provide enter the following details

Your First Name

Your Surname

Preferred Phone

Mobile PhoneFixed-line Phone

Phone

Mobile Phone

Email Address

Age

Name of person completing this form

Neurological condition name

Are you a member of MS Ireland or do you avail of support from a branch or region?

YesNo

Would you like to be added to MS Ireland's members database?

YesNo

Which branch or region?

Are you a member of another charity or support group?

YesNo

Name of charity or support group

Do you use a walking aid?

YesNo

Have you had a fall within the last three months?

YesNo

If Yes, how many falls have you had within the last three months?

Have you had any near misses, or almost fall, or catch yourself before you fall?

YesNo

Active Neuro will have a number of different programmes. Please select whichever sounds most suitable to you.

What is your preferred class time

MorningAfternoonEvening

Have you previously completed an Active Neuro programme?

YesNo

If Yes, can you still participate to the same level and with the same intensity as previously?

YesNo

Have you changed your medication in any way since you last completed an Active Neuro programme?

YesNo

Have you suffered any illness or injury since you last completed an Active Neuro Programme?

YesNo

Have you had any meetings with a GP or doctor for a new issue since you last completed an Active Neuro programme?

YesNo

GDPR and Consent - In order for the Active Neuro project to comply with current General Data Protection Regulations (GDPR) we are required to obtain your formal consent to gather and use information about you. Under this regulation the Active Neuro project and MS Ireland must adhere to the following:

· Valid consent must be explicit for the data collected and the purposes the data is used for

· The consent does not imply consent forever

· The data must only be used for the purpose it was initially intended for and no other

The first part of the data we collect will be used to ensure your safety and suitability to participate in the Active Neuro Programmes. (Medical history, Medication list and Physical Activity Readiness Questionnaire). This data will be collected over the Zoom assessment and is stored on our secure online servers and encrypted laptops.

The other data we gather will be during an individual consultation using Zoom for healthcare and an initial assessment on Form Assembly. The questionnaires and information gathered will be used to evaluate the effects of the programme or to tailor the programme for you. You will complete the same questionnaires before and after the programme. We will also record information about how you are completing the programmes.

Your data will be stored in secure offices or on encrypted laptops for the duration of the project and for 7 years afterwards (based at MS Ireland, Tara House). Only the Active Neuro project team will have access to your individual data.

The data in the questionnaires you complete before and after the programmes will be entered into MS Ireland's SalesForce systems and analysed as group averages with no sharing of individual data. The aggregated (and hence anonymous) data from all participants will be used in project reports or in presentations to professional groups or to health funders. We may ask if we can use your information for a case study and you can choose if this is anonymous.

Therefore, the Active Neuro programme requires you to consent to the following:

I consent to the Active Neuro project staff collecting, processing, analysing, and storing the data associated with providing me with an exercise programme or treatment

I consent to the Active Neuro project creating and updating a file with my data

I consent to be assessed and treated by the physiotherapist or exercise personnel using Zoom for healthcare

Yes - I consent to the GDPR policy outlined aboveNo - I do not consent to the GDPR policy outlined above
[Please note without your consent to our GDPR policy MSIreland will not be in a position to offer you this program and as such you will not be able to submit this form]

If you have any special requirements, concerns or requests, you may note them below:

Thank you for completing this form which will be reviewed shortly by the Active Neuro Physiotherapy team.

If you have queries please contact either; Susan: SusanC@ms-society.ie 086-036-4109 Mary: MaryBu@ms-society.ie 080-777-7281

Jack: JackM@ms-society.ie 086-074-9628

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