E-mail adress

Patient's first and last name

Passport number

Date of birth

Patient's address

Weight and height

Diagnosis

Forced break - whether the child needs a break for lunch, sleep or taking medication. If so, what are the break times?

Therapy hours - we work from 8am to 5pm. Can your child receive therapy during these hours What hours can your child have classes - specify the hours

The functional state of the child - please provide a short description of the child's motor skills (e.g. quadruple, sitting alone, not walking alone, no head control and what are you currently working on, etc.)

Current physiotherapy - proszę wypisać, czy była prowadzona intensywna fizjoterapia i jakimi metodami, np. Vojta, Medek, NDT Bobath

Orthopedic supplies - please list the equipment you have, e.g. AFO orthosis, standing frame, active wheelchair).
Please take your child's orthopedic equipment with you, such as orthoses, suits, etc.

Associated diseases (e.g. epilepsy, heart diseases) - please bring medical documentation, e.g. EEG test result

Pharmacotherapy - if the child is taking any medications, please list the medications

Treatment with botulinum toxin - was botulinum administered, if so, how many times and when was the last time

Surgical procedures - please specify what procedures and when were performed

Communication method - cognitive development - please describe how the child communicates, what is the child's level of cognitive development

Personal data of the legal guardian - name and surname of the legal guardian, telephone number, email address, legal guardian's residence address

Preferred date of arrival