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Client Information Form

Please fill out the following completely and accurately.

Date:

Client with neurological mobility condition

Name:

Age:

Date of Birth:

Address:

Cell phone:

Email address:

Disability/Diagnosis:

Disability/Diagnosis Details:

Height:

Weight: lbs.

Primary Language Spoken/Understood:

Parent/Guardian Information

(Necessary for clients under 18 years of age)

Name:

Relation:

Address:

Cell/Work Phone:

Email address:

Primary Language Spoken/Understood:

Emergency Contact Information

(if different from Parent/Guardian)

Name:

Relation:

Cell phone:

Work phone:

Primary Language Spoken/Understood:

Physician Information

Name:

Name of Facility:

Office Phone:

Location (City/State):

To be completed by the client or parent/guardian – please answer all questions that pertain to the client.

Have you sustained a spinal cord injury?

Yes

Level of SCI:

Cause of SCI:

Date of SCI:

Surgery date and procedure:

If you experience autonomic dysreflexia, do you know when it's happening?

Please describe usual presentation and trigger:

Have you sustained a traumatic brain injury?

Yes

If yes, please describe:

Are you able to walk?

Yes

If yes, do you use braces?

Yes

What type of assistive device do you use (i.e., crutches, walker, AFO, KAFOs)?

What are your primary means of mobility (i.e., power chair, manual wheelchair, cane, walker)?

Do you need assistance with any transfers to and from your wheelchair?

Yes

If yes, how much assistance do you need:

Have you ever had a bone density scan/DEXA scan?

Yes

If yes, when and what were the results:

Have you ever been diagnosed with osteopenia or osteoporosis?

Yes

Have you had any seizures in the last two years? Please Describe:

Do you have scoliosis?

Yes

Do you have heterotropic ossification or history of H.O?

Yes

Do you have pain?

Yes

Please describe if so:

Do you have a catheter, feeding tube, baclofen pump or other devices? (i.e. deep brain stimulator, etc.)

Yes

If yes, please describe:

Please list any other past medical history, surgeries, etc.:

Are you taking any medications:

Yes

List of medications:

How long has it been since you stood upright?

Do you ever get lightheaded or dizzy when you stand?

Yes

Do you have a standing frame:

Yes

If so, how often and for how long do you use it?

Do you currently have any open wounds (pressure sores, abrasions, cuts etc.) or a history of wounds?

Yes

If yes, where?

What is your living situation?

Do you have a visual impairment?

Yes

Do you have a hearing impairment?

Yes

Do you have or have had anxiety, depression, or aggression?

Yes

If yes, please describe:

Client’s Name (Please Print):

Client’s Signature: Clear

Date:

Parent/Guardian Name (Please Print):

Parent/Guardian Signature: Clear

Date:

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