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Patient History
Type of Cerebral Palsy
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Age Diagnosed (Years)
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1
2
3
4
5
6
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5
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10
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Has an MRI been done?
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N/A
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2
3
4
5
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1
2
3
4
5
6
7
8
9
10
11
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Birth
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Full Term
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Number of Weeks Gestation
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Weeks in the NICU
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Weeks on a Ventilator
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Birth Weight (Pounds)
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Birth Weight (Ounces)
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Intraventricular Hemorrhage (IVH)?
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Yes
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Comments
Previous Orthopedic Surgeries (Note type of surgery, month and year)
History of BOTOX Injections (Note month and year of most recent injection and muscles injected)
History of Back/Leg Pain
Have hip X-rays been done?
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Yes
No
If yes, how recently?
Developmental Level
Can patient sit independently in any position, including "w"?
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Yes
No
Can patient creep?
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Yes
No
Primary Type of Creeping
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Commando
Bunny Hop
Reciprocal
Can patient move on their own without a device?
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Yes
No
Can patient move on their own with a device?
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Yes
No
Not Applicable
Type of Device
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Forward Walker
Forearm Crutches
Straight Canes
Reverse Walker
Quad Canes
One Forearm Crutch or Cane
Has a gait analysis been done?
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Yes
No
Comments
Can the patient speak?
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Yes
No
If yes, is speech delayed?
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No
Comments
How often does the patient see a therapist?
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Therapist Name
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Last Name
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Chile
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Christmas Island
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Equatorial Guinea
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Gabon
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Greenland
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Guinea-Bissau
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Mali
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Moldova
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Mongolia
Montenegro
Montserrat
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Nagorno-Karabakh
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Philippines
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Poland
Portugal
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Qatar
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Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
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Tuvalu
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United Kingdom
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Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
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Other
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