FORM "C"

PLEASE FILL IN ONLY THE RELEVANT INFORMATION FOR YOURSELF,
YOUR CHILD OR YOUR WARD

Please take note that we utilize a holistic approach to the treatment of Neurological Disabilities for children and adults. Our treatment plan involves
our ability to utilize specialized developmental & functional neurological rehabilitation techniques, diet and nutritional counseling and lifestyle management. In order to prescribe an effective treatment plan for our patients we require that you complete this questionnaire honestlyand accurately to the best of your ability. If you have any questions or concerns about this questionnaire please call our office and we will assist you.

Date: _____________________________

Name of Patient: ______________________________________________

Date of Birth: ________________ Present Age: Years: _____Months:____

Sex of Patient: _______ Birth Weight: __________ Current Weight: ______

Occupation: _______________________ Marital Status: ______________

Formal Education: _____________________________________________

Disability (diagnosis if known): ___________________________________

____________________________________________________________

____________________________________________________________

CONTACT INFORMATION

Address:_____________________________________________________

City: ________________ Province: ____________ Postal Code: _________

Home #_______________ Work # ______________ Fax # _____________

E-mail: __________________________Cell Phone: ___________________

DETAILS OF SPOUSE OR NATURAL MOTHER, GUARDIAN

Name: _______________________________________________________
Relationship to Patient: __________________________________________
PROVIDE DETAILS IF PREVIOUSLY NOT PROVIDED OR DIFFERENT FROM ABOVE
Address:_____________________________________________________
_____________________________________________________________
Home Telephone: _________________________________________________
Work Telephone: _______________________________________________
Occupation: ___________________________________________________
Employer: _______________________________________________________
Formal Education: ______________________________________________
E-Mail:________________________________________________________
Age: _________________________________________________________

DETAILS OF SPOUSE OR NATURAL FATHER, GUARDIAN

Name: _______________________________________________________
Relationship to Patient: ____________________________________________
PROVIDE DETAILS IF PREVIOUSLY NOT PROVIDED OR DIFFERENT FROM ABOVE
Address: _____________________________________________________
_____________________________________________________________
Home Telephone: _________________________________________________
Work Telephone: _______________________________________________
Occupation: ___________________________________________________
Employer: _______________________________________________________
Formal Education: ______________________________________________
E-Mail:________________________________________________________
Age: _________________________________________________________

Please list the name, age, and relationship of all family members living in the
household: Name Relationship Age
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

MEDICAL DOCTOR INFORMATION – Names of neurosurgeon, neurologist,
cardiologist, radiologist, endocrinologist, pediatrician, pediatric specialists,
general practitioner, etc.

Name of Medical Doctor:_________________________________________

Nature of Specialty: _____________________________________________

Address: _____________________________________________________

____________________________________________________________

Tel. #: ________________________________________________________

Fax #: ________________________________________________________

Name of Medical Doctor:__________________________________________

Nature of Specialty: ______________________________________________

Address: ______________________________________________________

_____________________________________________________________

Tel. #: ________________________________________________________

Fax #: ________________________________________________________

Confidential Patient Information

1. How did you find out about AND?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

2. What is the problem/diagnosis?__________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

In your own words, explain the very first time that you noticed this condition
(provide a date if possible) and describe carefully any factors that you suspect
may have played a role in its onset and development. _____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

3. What is the patient’s present weight? Weight: ________________________

4. What is the patient’s height? Height:________________________

5. Please list any attempts at rehabilitation and briefly describe the results:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

6. Are you currently working with a professional counselor, psychologist,
social worker, or other therapist? Please provide details:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

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