(You also must print and fill out a Medical Clearance Form
that will be sent to the CNR.)
Please fill out as completely as possible and submit your history form.
The History Form and the Doctor's Note are for United States patients only.
Street Address
City State Zip Code
Phone Number Fax Number
Date of Birth Race Sex Male Female
Occupation
Work Phone Work Fax
Present Health
Mother or Legal Guardian
Occupation
Work Phone Work Fax
Present Health
Spouse if the Patient is Married
Occupation
Work Phone Work Fax
Present Health
List the name, age and relationship of all family members living at home
Name Age Relationship
Name Age Relationship
Name Age Relationship
Name Age Relationship
Name Age Relationship
Describe in your own words the present problem
How did you learn about our service
List any general health concerns
Describe any eating difficulties
Describe any sleeping difficulties
Total amount of sleep per day in hours
Describe any behavior problems
List all orthopedic problems
List all surgeries
List all hospitalizations for serious illness
List serious accidents and dates
List schools attended and results achieved
List rehabilitation programs you have tried and their results
If your child has seizures, please complete the following:
Describe a typical seizure
How long do they last, give the range if variable
When did the first seizure occur
When was the most recent seizure
List all medications and vitamins now being used
Outline a typical daily schedule
List activities of special interest to the patient past and present
Please list specific goals you would like to achieve
Tell us anything else you feel is important
Does everyone attending this visit speak English?
If not English, please specify what language
When the form is completed, use the SEND to CNR button to send your answers, or the reset button to reset all your answers and start over.
You also must print and fill out a Medical Clearance
Form
that will be sent to the CNR.
Send questions and/or comments to
Dr. Unruh at
DrUnruh@aol.com
Text and images on this page are
copyrighted by Dr. Unruh
at The Centre For Neurological Rehabilitation. All rights are reserved.
of West Chester University.