APPLICATION FORM                                                                                 

FIRST NAME: ____________________           LAST NAME ________________

SEX: ___________                           DATE OF BIRTH: _____________________  

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BRIEF MEDICAL/SURGICAL HISTORY : _______________________________

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HEART PROBLEMS:______________________________________________

DIABETES: _____________________________________________________

SEIZURES (date of the last ones): ____________________________________

SCOLIOSIS: _____________________________________________________

 VISION/HEARING: ________________________________________________

SHUNTS (hydrocephalus): __________________________________________

TRACHEAL/C-TUBE: ______________________________________________

COGNITIVE DEVELOPMENT: _______________________________________

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

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

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 COMMUNICATION ABILITIES ( specify ): _______________________________

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LIST ANY SUPPORTING EQUIPMENT USED BY THE PATIENT

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

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THE FOLLOWING ITEMS MUST BE ATTACHED 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 :       ________________________________