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First name and last name of person filling out form
First name and last name of the patient
Date of Birth
Strongly recommended that the accompanying person will be the same individual who will continue to take care of the patient at home.
First name and last name, relationship to the patient
Information about the disease and the patient's condition
Please describe in your own words the main difficulties experienced by the patient, when these difficulties began and the patient's current condition
General condition of the patient on the day of filling in the questionnaire
Is the patient conscious?
Does the patient react to elementary requests, i.e. to close his eyes, raise his hand, etc?
What is the general cognitive status of the patient? Is the patient capable of relating to himself / his situation / time / space / environment / caretaker / others?
Are there any speech disorders? If so, please describe?
Are there any motor disorders? (i.e. difficulties in moving a hand, arm, leg and/or foot)? If so, which type of disorder? How does the patient move? Does he use any device for support or to assist in moving a limb?
Does the patient suffer from partial/complete urinary and/or bowel incontinence (i.e. the partial or complete loss of urinary and/or bowel control)?
Does the patient have any background diseases (diabetes, hypertension, other)?
Does the patient take any medications on a regular basis?
Please estimate how long after receiving our invitation you plan to start the process of rehabilitation in our clinic?
Please scan and upload the latest medical findings, as well as the results of tests and examinations, from the last six months.
Please also bring ALL OTHER DOCUMENTS AND IMAGING RESULTS (CT / MRI/ PET /US) with you to our clinic. Please upload your files (maximum file size: 2 MB): Permitted file types: pdf, gif, jpg, png, bmp, txt, rtf, doc, docx, xls, xlsx.
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