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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:

Home phone:

Cell phone:

Email address:

Disability:

Disability details:

Height:

Weight: lbs.

Primary language spoken/understood:

Have there been any seizures in the last two years?

Is the client ambulatory?

Yes

What are the client’s primary means of mobility (i.e., power wheelchair, manual wheelchair, cane, walker, etc.)?

Parent/Guardian Information

(Necessary for clients under 18 years of age)

Name:

Relation:

Address:

Home phone:

Cell phone:

Work phone:

Email address:

Primary language spoken/understood:

Emergency Contact Information

(if different from Parent/Guardian)

Name:

Relation:

Home phone:

Cell phone:

Work phone:

Primary language spoken/understood:

Physician Information

Name:

Location (City/State):

Office phone:

Home phone:

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

If not, please indicate other diagnosis and cause:

Level of SCI:

Incomplete

Complete

Date of injury:

Cause of injury:

Surgery Date:

Surgery Procedure:

Have you sustained a traumatic brain injury?

Yes

If yes, please describe:

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

Are you able to walk?

Yes

If so, do you use braces?

Yes

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

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

Yes

If so, how much assistance is needed?

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

Yes

If so, when and what were the results?

Have you ever been diagnosed with osteopenia or osteoporosis?

Yes

Have you ever fractured a bone?

Yes

If so, when and what bone did you fracture?

Do you have full strength in both your arms?

Yes

If no, what is limited (i.e., grip, shoulder strength, etc.)

Any history of shoulder injuries (i.e., dislocation, rotator cuff tear etc.)?

Yes

If yes, please describe what and when

Any history of, or current, orthopedic injuries pertaining to back, hips, knees,shoulders, etc.?

Yes

If yes, please describe:

Do you have heterotopic ossification or a history of H.O.?

Yes

If yes, where was/is it?

Are you taking any medications for pain or any other conditions (i.e., spasticity or nerve pain)?

Yes

If yes, what are the side effects and how often do you take them?

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?

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

Yes

Please describe usual presentation and trigger:

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

Yes

If yes, where and/or when?

Do you have a visual impairment?

Yes

Do you have a hearing impairment?

Yes

OTHER: Please describe any other disability, disease or disorder that we should be aware of:

Client’s Signature: Clear

Date:

Client’s Name (Please print):

Parent/Guardian Signature: Clear

Date:

Parent/Guardian Name (Please print):

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