Application form


Typed data relate of the stay: XXXVII in Szklarska Poręba from 2019-06-30 to 2019-07-13

ALL FIELDS ARE REQUIRED

Personal data

First name:
Surname:
Date of birth:
Age:
Country:
Place of resident:
Postal code:
Address:
Mobile phones of parents:
E-mail:

History of treatment

Sex of the participant of the stay:
M
W
If menstruate, enter the date of when (month, year), if not enter "NO"

Date of implementation of the first radiographs (month, year) (if there is not type: "No"):
Date of implementation of the last radiographs (month, year) (if there is not type: "No"):

Scoliosis by the Cobb angle from the last radiographs (if not have scoliosis in the specified section, please enter '0')


Thoracic scoliosis:
Scoliosis thoraco-lumbar:

Scheuermann's disease:
No
Yes
Enter the thoracic kyphosis angle (if there is not type: "0"):

Other diseases (describe what) (if there is not type: "No"):

What therapeutic methods was a child treated so far? (Enter month and year start) (select at least one method)


If the child has not been treated by any of the methods, select each option and enter in the "No"
FITS (since when?):
Dobomed (since when?):
SEAS (since when?):
LYON (since when?):
Schroth (since when?):
Other (Specify?):
Since when the child is under rehabilitation (month, year) (if there is not type: "No"):

Name and place of group practice child (if there is not type: "No"):


Name and surname orthopaedist, under whose control the child (if there is not type: "No"):


Surname and first name the physiotherapist (if there is not type: "No"):



Does your child wear a corset:
No
Yes
Since when (month, year):
Type of corset:
Time to wear: Night Day
How many hours a day:


Is the last 6 months scoliosis has worsened:
No
Yes
How many degrees:


The health status of the child

Past child injuries (falls, accidents, fractures, sprains, dislocations and other) (if there is not type: "No"):


Transferred child operations * In the absence of surgery, please enter "None". In the case of operations, please provide the operating area and date (month and year or year itself) (if there is not type: "No"):


Coexisting diseases - describe how and from when (if there is not type: "No"):


Are assumes constant medication and in what doses (if there is not type: "No"):


What is allergic (if there is not type: "No"):


Does your child have diabetes:
No
Yes

Immunizations (enter the year) (if there is not type: "No"):


Do you wear braces:
No
Yes

Do you wear glasses:
No
Yes
How many diopters:

How hates driving car:


Is swims, which style? (if don't swim type: "No")



I conclude that gave / I gave all the information known to me about the baby, which can help to provide proper care during their stay at turnusie scoliosis.

I agree to the introduction of the database and the processing of my personal data now and in the future by the Cabinet of Physiotherapy Proteins Marianna in Jawor (in accordance with the provisions of the Act of August 29, 1997. Privacy Policy - OJ No. 101 of 2002. Pos .926, as amended)


Name of the person completing form:


The invoice / bill

The name of the employer or name:


Postal code:
Place of resident:
Address: