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Requested
Illustration:
1.
WHAT CAUSED YOUR PARALYSIS?
TRAUMA, GIVE DETAILS AND DATE OF OCCURRENCE
SURGERY, GIVE DETAILS INCLUDING REASON FOR SURGERY AND DATE OF OCCURRENCE
STROKE OR CEREBRAL VASCULAR ACCIDENT
OTHER DISEASE, PLEASE GIVE DETAILS
2. PLEASE NOTE CURRENT LEVEL OF FUNCTION:
INCOMPLETE PARAPLEGIA
COMPLETE PARAPLEGIA
INCOMPLETE QUADRIPLEGIA
COMPLETE QUADRIPLEGIA
3. IF PARALYSIS FROM INJURY OR TRAUMA, AT
WHAT SPINAL CORD LEVEL (LIST SPECIFIC VERTEBRAE AVAILABLE, I.E. C7-8)
CERVICAL SPINE
THORACIC SPINE
LUMBROSACRAL SPINE
4.
HAVE ANY OF THE FOLLOWING OCCURRED:
(CHECK ALL THAT APPLY)
PNEUMONIA
SKIN ULCERS
URINARY TRACT INFECTION
KIDNEY IMPAIRMENT
DEPRESSION5.
5.
ARE THERE ANY CURRENT SYMPTOMS OR COMPLICATIONS:
(CHECK ALL THAT
APPLY)
NORMAL BLADDER FUNCTION
NEEDS ASSISTANCE ( FOR ABOVE)
NORMAL BOWEL FUNCTION
NEEDS ASSISTANCE ( FOR ABOVE)
6.
WHAT TREATMENT IS CURRENTLY BEING PRESCRIBED?
LIST MEDICATION AND DOSAGE
7.
CLIENT'S OCCUPATION
8. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL
9. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL
10.
PLEASE LIST ANY OTHER ILLNESSES OR
IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:
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