+48 22 120 20 50
+48 22 559 21 37
Patient's first and last name
Date of birth
Weight and height
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
MRI, ultrasound, medical records, X-ray of the hip joints, X-ray of the spine