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Participant
*
Parent/Guardian Name (if under 19)
*
DOB
*
+
Height
*
Weight
*
E-mail
*
Phone Number
*
Address
*
Diagnosis
*
Date Onset
*
Medications
*
Physician Name
*
Physician Phone Number
*
Does Participant Have Any Allergies? If Yes, Please Specify:
*
Does Participant Suffer from Seizures
*
Yes
No
If Yes, Are They Controlled?
*
Yes
No
Date of Last Seizure
+
Special Precautions/Needs
*
Mobility
*
Independent Ambulation
Yes
No
Assisted Ambulation
Yes
No
Wheelchair
Yes
No
Braces/Assistive Devices
Please indicate current or past difficulties in the following systems/ares, including surgeries:
*
Auditory
Yes
No
Visual
Yes
No
Tactile Sensation
Yes
No
Speech
Yes
No
Cardiac
Yes
No
Circulatory
Yes
No
Integumentary/Skin
Yes
No
Immunity
Yes
No
Pulmonary
Yes
No
Neurologic
Yes
No
Muscular
Yes
No
Balance
Yes
No
Orthopedic
Yes
No
Allergies
Yes
No
Learning Disabilities
Yes
No
Cognitive
Yes
No
Emotional/Psychological
Yes
No
Pain
Yes
No
Other
Yes
No
Please Be Specific for Anything you Selected Yes for Above:
*
Special Considerations
*
Noise Sensitivity
Vision Impairment
Hearing Impairment
Mobility Impairment
Autism
Non-Verbal
Cerebral Palsy
Downs Syndrome
Muscular Dystrophy
Multiple Sclerosis
Other
If other please specify:
*
Other Specialist Caring for Child
Payment Preference
*
Self-Pay
Insurance
Additional Parent Comments/Concerns
*
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