APPLICATION FORM                                                                                 

FIRST NAME: ____________________           LAST NAME ________________

SEX: ___________                           DATE OF BIRTH: _____________________  

FAMILY COMPOSITION;

OTHER CHILDREN:_______________________________________________

PARENT’S/GUARDIAN’S NAME:_____________________________________

ADDRESS: _____________________________________________________

PHONE: ___________________________

FAX: ______________________________

E-MAIL: _______________________________________

PATIENT`S DIAGNOSIS AND WHEN WAS IT MADE: ____________________

  ______________________________________________________________

_______________________________________________________________

BRIEF MEDICAL/SURGICAL HISTORY : _______________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

HEART PROBLEMS:______________________________________________

DIABETES: _____________________________________________________

SEIZURES (date of the last ones): ____________________________________

SCOLIOSIS: _____________________________________________________

 VISION/HEARING: ________________________________________________

SHUNTS (hydrocephalus): __________________________________________

TRACHEAL/C-TUBE: ______________________________________________

COGNITIVE DEVELOPMENT: _______________________________________

 _______________________________________________________________

IS THE PATIENT TAKING ANY MEDICATIONS? (If yes,please specify): ________

 _______________________________________________________________

PATIENT`S ABILITIES (rolling, sitting, crawling, walking): ___________________

_______________________________________________________________

 _______________________________________________________________

 _______________________________________________________________

 COMMUNICATION ABILITIES ( specify ): _______________________________

 _______________________________________________________________

LIST ANY SUPPORTING EQUIPMENT USED BY THE PATIENT

(braces/splints, walker, crutches, canes, etc.): ____________________________

 _____________________________________________________________

_______________________________________________________________

 _______________________________________________________________

THE FOLLOWING ITEMS MUST BE ATTATCHED TO THIS FORM:

HIP X-RAY IN ADDITION TO ANY OTHER PROBLEMATIC PART.

ANY AVAILABLE MEDICAL REPORTS.

VIDEO RECORDING ( VCR ) SHOWING THE ABILITIES OF THE PATIENT.

  Parent Name : ________________________________ 

  Signature :       ________________________________