Selective Dorsal Rhizotomy (SDR) Evaluation Request

I would like to:*

Schedule an appointment.Send a video of a patient for evaluation.
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*
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.
Relationship to Patient*
Patient History
Type of Cerebral Palsy*
Age Diagnosed (Years)*
Age Diagnosed (Months)*
Has an MRI been done?*

YesNo
MRI Age (Years)*
MRI Age (Months)*
Birth*

Full TermPremature
Number of Weeks Gestation*
Weeks in the NICU*
Weeks on a Ventilator*
Birth Weight (Pounds)*
Birth Weight (Ounces)*
Intraventricular Hemorrhage (IVH)?*

YesNo
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?*

YesNo
If yes, how recently?
Developmental Level
Can patient sit independently in any position, including "w"?*

YesNo
Can patient creep?*

YesNo
Primary Type of Creeping*

CommandoBunny HopReciprocal
Can patient move on their own without a device?*

YesNo
Can patient move on their own with a device?*

YesNoNot Applicable
Type of Device*

Forward WalkerForearm CrutchesStraight CanesReverse WalkerQuad CanesOne Forearm Crutch or Cane
Has a gait analysis been done?*

YesNo
Comments
Can the patient speak?*

YesNo
If yes, is speech delayed?*

YesNo
Comments
How often does the patient see a therapist?*
Therapist Name

First NameLast Name
Therapist Facility
Therapist Phone
Please enter a valid phone number.
Therapist Address

Street Address

Street Address 2

CityState / Province

Postal / Zip CodeCountry
Comments
Should be Empty:

Contact Information

Patient History

Developmental Level