Patient Information Your First Name Your Last Name Your Relationship to the Patient Patient's Name E-mail Address Patient's Date of Birth Patient's Age Child's Father's Name Child's Mother's Name Address Address Address 2 City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federate States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP/Postal Code Country - None - Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Ceuta & Melilla Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Côte d’Ivoire Denmark Diego Garcia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard & McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR China Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands North Korea North Macedonia Norway Oman Outlying Oceania Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Samoa San Marino Sark Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia & South Sandwich Islands South Korea South Sudan Spain Sri Lanka St. Barthélemy St. Helena St. Kitts & Nevis St. Lucia St. Martin St. Pierre & Miquelon St. Vincent & Grenadines Sudan Suriname Svalbard & Jan Mayen Sweden Switzerland Syria São Tomé & Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad & Tobago Tristan da Cunha Tunisia Turkmenistan Turks & Caicos Islands Tuvalu Türkiye U.S. Outlying Islands U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis & Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Phone number Cellular Phone How did you hear about us? Emergency Contact Name Phone Relationship to Patient History Type of Cerebral Palsy Diagnosed at (years) - None - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Diagnosed at (months) - None - 1 2 3 4 5 6 7 8 9 10 11 12 Has an MRI been done? Yes No MRI Age (years) - None - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 MRI Age (months) - None - 1 2 3 4 5 6 7 8 9 10 11 12 Birth Full term Premature Number of Weeks Gestation Weeks in NICU Weeks on Ventilator Birth Weight (Pounds) Birth Weight (Ounces) IVH No Yes If yes, then grade Comments Previous Orthopedic Surgeries (note type of surgery, month and year) History of BOTOX injections (note month and year of most recent injection and muscles injected History of Back/Leg Pain Have Hip X-Rays Been Done? No Yes If yes, how recent? Developmental Level Can patient sit independently in any position including "w"? Yes No Can patient creep? Yes No Primary type of creeping pattern? Commando Bunny Hop Reciprocal Ambulate independently with a device? Yes No Not Applicable Type of device? Forward Walker Forearm Crutches Straight Canes Reverse Walker Quad Canes One forearm crutch or cane Has a gait analysis been done? No Yes If yes, then when? Ambulate independently without device? No Yes If yes, distance (in feet)? Comments? Verbal Yes No Delayed? Yes No Comments? Times per week? Therapist's Name? Therapist's Facility? Therapist's Phone? Therapist's Address? Therapist's Address Address 2 City/Town State/Province - None - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federate States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming ZIP/Postal Code For evaluation purposes I would like to make an appointment with Dr. Roland would like to send a video for evaluation CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
