Patient Referral

Patient Information

To refer a patient to the Brachial Plexus Center, parents and physicians may contact:

Brachial Plexus Center
St. Louis Children's Hospital, Ste. 4S 20
One Children's Place
St. Louis, MO 63110

Phone: 314-454-2811
Fax: 314-454-2818
Toll Free: 800-416-9956
Email: [email protected]

Or you may complete this Initial Evaluation form online.

Patient's Address
Parent's Address
Race
Gender

History

Labor
Presentation
Birth
Delivery

Muscle strength at the time of this referral

Parents may need assistance from the physician or therapist in filling out this form.
(Note: Grade the best strength observed during evaluation.)

1: No or trace muscle contraction

2: Muscle contraction without gravity

3: Muscle contraction against gravity

4: Muscle contraction against resistance

NG: Not graded due to difficulties

Deltoid
Biceps
Triceps
Wrist Flexors
Wrist Extensors
Finger Flexors
Finger Extensors