Application form

The rehabilitation treatment takes at least two weeks.

 

It starts with the initial examination on Monday and ends with the final examination on Saturday.

SUBMIT

Name and surname:

Required

Thank you!

Your application form has been sent

1. Patient data

Male
Female

Required

Date of birth:

Required

Birth certificate No.:

Required

Diagnosis:

Required

Date of the last diagnosis:

Required

Health insurance company:

Required

Height of the patient:

Required

Weight of the patient:

Required

Size of shoes:

Required

Underwent surgeries:

Required

2. Parents/accompanying person data:

 

Name and surname:

Required

Date of birth:

Required

State:

:

Required

Permanent address:

Required

Mailing address:

Required

Phone number:

Required

E-mail:

Required

We need accommodation
during the rehabilitation stay:

Yes
No

Required

3. Health condition of the patient:

 

Patient has metals inside his or her body:

Yes
No

Required

Patient underwent chemotherapy or radiation therapy:

Yes
No

Required

Patient is taking immunosuppressants:

Yes
No

Required

Patient has osteoporosis:

Yes
No

Required

Patient’s chronic treatment
has been changed recently:

Yes
No

Required

The patient has an EMG or genetically confirmed muscular disease:

Yes
No

Required

Epilepsy:

Number of seizures during one month:

Required

Current medication:

Required

X-ray of hip joints and medical report: bring with you to initial examination

X-ray of arm joints and medical report: bring with you to initial examination

Heart defects:

Yes
No

Required

Scoliosis:

Yes
No

Required

Lordosis:

Yes
No

Required

Tracheostomy:

Yes
No

Required

Diabetes:

Yes
No

Required

Hydrocephalus:

Yes
No

Required

Shunts:

Yes
No

Required

Motoric abilities

Turning over:

Yes
No

Required

Crawling:

Yes
No

Required

Sitting:

Yes
No

Required

Standing up:

Yes
No

Required

Walking:

Yes
No

Required

Used aids (e.g. wheelchair, crutches etc.):

Required

Currently used drugs and reason of usage:

Required

Allergies:

Required

I have read the contractual terms of Renona Rehabilitation s.r.o. and agree with them. I hereby also confirm the validity of the above mentioned data.

Date:

Required

Signature:

Required

Thank you in advance. We are looking forward to your visit!

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