DATE OF BIRTH: ________________________ AGE: _______________________________

PARENT / GUARDIAN NAME: __________________________________________________

ADDRESS: ___________________________________________________________________

_____________________________________________________________________________

PHONE: HOME (_____)____________________ WORK (______)___________________

FAX: ______________________________________

E- mail: ____________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________


2. GIVE  MEDICAL / SURGICAL HISTORY:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

- HISTORY OF BOTOX/PHENOL INJECTIONS_________________________________________

- HISTORY OF INHIBITIVE / SERIAL CASTING  (DATES)_________________________________

- HISTORY OF FRACTURES________________________________________________________


3. WHAT IS THE CHILD'S:

- HEIGHT ______________________________________________________________________

- WEIGHT _____________________________________________________________________

4. CIRCUMFERENCES OF:

CHEST_________________________

WAIST________________________

THIGH__________________________

5. MEDICAL STATUS


- SEIZURES (date of last one) ____________________________________________________

- SCOLIOSIS __________________________________________________________________

- HEART PROBLEMS / HYPERTENSION / PAST HEART SURGERIES______________________

  _____________________________________________________________________________

- LUNGS PROBLEMS_____________________________________________________________ 

- DIABETES __________________________________________________________________

- VISION/HEARING _____________________________________________________________

- SHUNTS (hydrocephalus) _____________________________________________________

- TRACHEAL/G- TUBE __________________________________________________________

- KIDNEY PROBLEMS__________________________________________________________

PLEASE PROVIDE PHONE NUMBERS TO ALL SPECIALISTS WHO TREAT YOUR CHILD 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

6. PLEASE LIST ANY MEDICATIONS YOUR CHILD IS CURRENTLY TAKING (and reason for taking)

______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

7. CHILD ABILITIES (rolling, sitting, crawling, and walking):

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

8. LIST OF MEDICAL EQUIPMENT THAT YOUR CHILD IS USING:
    (braces, walker, crutches, wheelchair)

_______________________________________________________________________________

_______________________________________________________________________________

9. HOW DO YOU COMMUNICATE WITH YOUR CHILD / HOW DO THEY COMMUNICATE WITH YOU ?

_______________________________________________________________________________

10. IS YOUR CHILD ABLE TO FOLLOW SIMPLE COMMANDS:

_______________________________________________________________________________

11. HAVE YOU EVER BEEN  DENIED THERAPY AT EUROPEDS OR EUROMED CLINIC ?
       ( IF YES PLEASE EXPLAIN WHEN AND WHY )

_______________________________________________________________________________

_______________________________________________________________________________

12. PLEASE PROVIDE US WITH WRITTEN HIP X-RAY REPORT  (NO OLDER THAN 6 MONTHS)

PLEASE MAIL OR FAX COMPLETED FORM TO: