Returning Questionnaire

IMPORTANT NOTES!

Upon completing this form, there will be a section dedicated to attaching your most recent records, such as photos, documents, and videos. We recommend that, before you start filling out the form, you upload these files to a cloud folder and save the corresponding link. This link can be inserted in last page this form.

Client's Name

Date of birth

Age

Sex

Occupation

Diagnosis

Any change in the diagnosis?

Last Intensive Program (dates and number of weeks)

Any change on Personal Information? (Phone number, e-mail, address)

If yes, please, update your personal information

1. After the Intensive program, did you or your child return to his/her routine activities? Were you able to follow the home exercises program / orientations? If no, tell us what your difficulty was.

2. From the last intensive program to now, did you or your child have any complications? Pain? Allergy? Surgery?

3. From the last intensive program to now, did you or your child have Botox injections? Serial Casting?

4. Have you or your child had a consultation with an Orthopedic Doctor during this period? X-ray / Image exam updated?

5. Did you or your child have any seizure (s)? If so, how are the seizure (s) now? Still have? Stabilized with medication? If so, how often?

6. Medication, please list all the medications in use, including the reason, doses, and time of the day.

7. Feeding routine (describe which foods, frequency, and daily amount):

8. Bowel movement, describe your child daily frequency / consistency:

9. Do you or your child report any pain? If so, where, and when?

10. Behavior problems (aggressiveness, refusal, others. Please, list it all):

11. Equipment / orthoses / splint in use at home / school, describe when and how long is the use:

12. Training, sports, therapies, and activities that currently perform. How often, name of professional and place:

13. Functional Goal (s) for the intensive program at Neurowerks:

Please attach the following most recent records of the patient in cloud, and insert link below:

Update report: Personal trainer and/or Physiotherapist
Update report: Occupational Therapist
Update report: Orthopedic Surgeon
Update report: Neurologist
Update report: Pediatrician Physiatrist
Update report: other pertinent information.
Please provide us a photo and a written hip x-ray report (no older than 6 months).
In case of scoliosis, please provide us a photo and a written spine x-ray report (no older than 6 months).
Please provide update videos of your child doing some skills, ex: rolling, sitting, crawling, walking, running.
Please provide another update videos of your child doing some skills, ex: rolling, sitting, crawling, walking, running.

Cloud link (remember to grant access)

Name of whom filled the form:

Relation with patient:

Date:

Acceptance

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Returning Questionnaire

Thank You!