Application form: Cerebral Palsy
This application form should be submitted by the adult applicant or by a close relative, friend or professional advisor on his/her behalf.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone number
*
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Application made by (if different from above)
Status of this person in relation of applicant:
Applicant's full diagnosis (if known)
Do you work? If yes, mention occupation.
CURRENT STATE OF HEALTH
What would you describe as your main symptoms e.g. tremor spasticity etc. Please give as much details as possible of the parts of your body affected.
Do you have diabetes? If yes, what treatment do you take?
Have you had heart trouble? If yes, please give details.
Do you suffer from epilepsy? If yes, please write date of last fit, and frequency of this.
Have you suffered from high blood pressure / low blood pressure? If yes, what treatment/therapy has been given?
Do you take any regular medication? If yes, state below medication, how often is taken and dosage.
Have you had any operations? If yes, please give details and dates.
PRESENT ABILITIES
Please describe your present abilities and any aids used or assistance given the following areas:
Balance
Turning over in bed
Standing up from chair
Walking
In the house
In the street
Long distances
With what help
Do you have balance problems? If yes, please give details.
Do you often fall over?
How do you get up from the floor?
Dressing
Large garments
Buttoning, zips, etc.
General
Bathing/showering
Eating
Drinking
Writing
Please describe present ability of the following
Vision
Hearing
Understanding of speech
Verbal communication (describe any aids used)
Memory (short term / long term)
Do you have any problems with continence?
Do you use a catheter? If yes, please state type and help required if any.
GENERAL MEDICAL INFORMATION
Describe any other specific difficulties not coverned above e.g. joints
Please give details of any kind of therapy/treatment you have received.
Have you had any other serious illness? If yes, please give details
Please list all substances/materials you produce an allergy to with a specific description of your reaction
FURTHER INFORMATION
Are you aware of the fees per session?
Yes
No
Have you ever participated in Conductive Education? If yes, where did this take place? Please give date of assessment and dates of any longer stays.
It would be helpful if you could state below where you first heard/read about Conductive Education.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: