SCOTTISH STROKE NURSES FORUM
Membership Request Form
Membership of the Scottish Stroke Nurses Forum (SSNF) is for all nurses with an interest in stroke
working in Scotland.
Membership is free. Joining is easy, simply complete this short form and return it to the SSNF
Secretary (details at the end of the form). Your details will then be held on a secure database.
Student nurses will be removed from the membership on graduation and require to re-apply on
registration.
As a member, periodically you will be sent communications and invitations to participate in
related research studies.
Title (circle): Mr Mrs Miss Ms Dr Prof
Gender(circle): Male Female
First Name:
Surname:
Organisation/Address:
Postcode:
Date of graduation if student (mandatory):
Telephone:
University (if student):
E-mail (highly desirable):
Health Board Area (tick one)
Ayrshire & Arran
Borders
Dumfries & Galloway
Forth Valley
Fife
Grampian
Greater Glasgow & Clyde
Highland
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Lanarkshire
Lothian
Orkney
Shetland
Tayside
Western Isles
Scotland wide
Other (specify)_______________
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District Nurse
Public Health Nurses
Practice Nurse
Manager
Lecturer
Researcher
Non –registered nurse
Student
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Main Area of Work (tick one)
Clinical Practice
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Management/Leadership
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Research
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Education
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Quality/Audit
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Other (specify)_____________□
Position (tick one)
Charge Nurse/Ward Manager □
Senior Staff Nurse
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Staff Nurse
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Enrolled Nurse
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Nurse Consultant
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Stroke Coordinator
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Stroke Nurse Specialist
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Stroke Liaison Nurse
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Other (specify)_______________
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Current Base (tick one)
Acute Stroke Unit
Stroke Rehabilitation Unit
Integrated Unit (acute/rehabilitation)
Mixed Ward (with designated stroke beds)
Medical Ward
Care of the Elderly Ward
General Practice
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Community Team
Day Hospital
Residential/Nursing Home
University
Office Based
Outpatients
Other (specify)_______________
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Areas of Stroke Interest: where you are willing to be consulted on – your top 3
(Tick up to 3 maximum)
Communication Problems
Oral Care
Swallowing and/or Nutrition
Mobility Issues
Sensory Problems
Activities of Daily Living
Skin Care
Perceptual Problems
Psychological Effects
Cognitive Problems
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Continence Management
Visual Problems
Sexual Issues
Sleep Issues
Palliative Care
Complications of Stroke
Pain Management
Social Aspects
Spiritual Aspects
Secondary Prevention/
Lifestyle changes
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I hereby request to become a member of the Scottish Stroke Nurses Forum and accept the
conditions as detailed:
Sign___________________________________________________________ Date________
Thank you completing this form
Please return it to:
Campbell Chalmers
Chair, Scottish Stroke Nurses Forum
Glen Lyon Building, Locality Offices, Coathill Hospital, Coatbridge ML5 4DN
Tel: 01236 703108 Email: campbell.chalmers@lanarkshire.scot.nhs.uk
The SSNF is kindly supported by Chest Heart & Stroke Scotland