Selective Dorsal Rhizotomy (SDR) Evaluation Request

I would like to:
Your Name

First NameLast Name
Your Relationship to the Patient
Patient Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Patient's Mother's Name

First NameLast Name
Patient's Father's Name

First NameLast Name
Contact Information
Your Phone Number
Format: (000) 000-0000.
Your Email Address
Your Address

Street Address

Street Address 2

CityState

Zip CodeCountry
How did you hear about us?
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Patient History
Type of Cerebral Palsy
Age Diagnosed (Years)
Age Diagnosed (Months)
Has an MRI been done?
MRI Age (Years)
MRI Age (Months)
Birth
Number of Weeks Gestation
Weeks in the NICU
Weeks on a Ventilator
Birth Weight (Pounds)
Birth Weight (Ounces)
Intraventricular Hemorrhage (IVH)?
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?
If yes, how recently?
Developmental Level
Can patient sit independently in any position, including "w"?
Can patient creep?
Primary Type of Creeping
Can patient move on their own without a device?
Can patient move on their own with a device?
Type of Device
Has a gait analysis been done?
Comments
Can the patient speak?
If yes, is speech delayed?
Comments
How often does the patient see a therapist?
Therapist Name

First NameLast Name
Therapist Facility
Therapist Phone
Please enter a valid phone number.Format: (000) 000-0000.
Therapist Address

Street Address

Street Address 2

CityState / Province

Postal / Zip CodeCountry
Comments
Should be Empty:

Contact Information

Patient History

Developmental Level