Published on
Source
(
https://dev.asksource.info
)
Home
>
User account
> User account
(If you're a human, don't change the following field)
Enter your name
Your first name.
Please enable Javascript to use this form.
(If you're a human, don't change the following field)
Enter your name
Your first name.
Please enable Javascript to use this form.
User details
First name
Last name
Username
*
Spaces are allowed; punctuation is not allowed except for periods, hyphens, apostrophes, and underscores.
E-mail address
*
A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.
Organisation
Job title
Country
Gender identity
*
- Select a value -
female
male
non-binary/third gender
not listed
prefer not to say
Short Set of Washington Group Questions
The next questions ask about difficulties you may have doing certain activities because of a health problem
Do you have difficulty seeing, even if wearing glasses?
*
- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Do you have difficulty hearing, even if using a hearing aid?
*
- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Do you have difficulty walking or climbing steps?
*
- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Do you have difficulty remembering or concentrating?
*
- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Do you have difficulty (with self-care such as) washing all over or dressing?
*
- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Using your usual (customary) language, do you have difficulty communicating, for example understanding or being understood?
*
- Select a value -
No - no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
Prefer not to say
Select the newsletter(s) to which you wish to subscribe.
Plain text only
HTML version
Source URL:
https://dev.asksource.info/user/register?destination=node/66229%23comment-form
