Medical Statement

Medical Statement

Client Record (Confidential Information)
Submitting this form does not guarantee enrollment in specialized services at DRIVEN NeuroRecovery Center. All submissions will be reviewed by the Director of Neuro Services to assess eligibility. DRIVEN and its representatives retain sole discretion in determining program participation and reserve the right to decline services.
Medical Information

Incomplete Medical Statements will not be reviewed. All fields must be completed before your submission can enter the review process. If a field does not apply to you, enter “N/A.”
Name*

First NameLast Name
Gender / Gender Identity
Spinal Cord Injury (SCI)Traumatic Brain Injury (TBI)Multiple Sclerosis (MS)StrokeCerebral Palsy (CP)Other
If MS, what type?*
If SCI, what was the cause of injury?*
Level of injury*
ASIA score (at time of injury)*
ASIA score (current)*
Date of Injury / Diagnosis*

MonthDayYear
Date
Name of Hospital Where Initially Treated*
Location of Hospital Where Initially Treated (City, State)*
Start Date of Initial Inpatient Treatment

MonthDayYear
Date
End Date of Initial Inpatient Treatment

MonthDayYear
Date
YesNo
If yes, what was the name of the specializing hospital?
Location of Specializing Hospital (City, State)
Start Date of Treatment at Specializing Hospital

MonthDayYear
Date
End Date of Treatment at Specializing Hospital

MonthDayYear
Date
Please answer "Yes" or "No" to the following. Indicate “Yes” for those that either currently apply to you or have applied to you in the past.

Do you have:
YesNo
YesNo
YesNo
YesNo
If yes, explain:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, specify which bones were fractured and when?
YesNo
YesNo
YesNo
YesNo
If yes, specify and note onset / diagnosis date:
YesNo
If yes, specify type and date of diagnosis:
YesNo
If yes, specify and note date(s) of injuries:
YesNo
YesNo
YesNo
Yes (Past)Yes (Present)No
If yes, how many / how many packs did / do you smoke per day?
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, explain intensity and frequency:
YesNo
If yes, explain intensity and frequency:
YesNo
If yes, specify hardware, when it was implanted and any issues that have arisen since implantation:
YesNo
If yes, explain:
YesNo
If yes, explain when you experience it and what your symptoms are:
YesNo
If yes, explain:
YesNo
If yes, explain:
YesNo
If yes, explain:
YesNo
If yes, explain your symptoms and preventative measures:
YesNo
If yes, specify location, stage and status:
YesNo
If yes, explain:
YesNo
YesNo
YesNo
If yes, explain:
Please answer the following questions completely and thoroughly.
List ALL assistive devices you use in everyday life, even if only for short periods (i.e. walker, type of wheelchair, AFO, abdominal binder, etc.)*
Describe your physical abilities including controlled/uncontrolled movements, tone and/or spasms or joint issues. Be as specific as possible.
Upper Extremity (Arms, Hands, and Fingers): *
Trunk (Back and Abdominals): *
Lower Extremity (Hips, Legs, Feet, and Toes): *
List ALL other physical challenges or special considerations (i.e. limits in range of motion, knee instability, joint/muscle disorder, other health issues, etc.): *
YesNo
If no, describe the level of support you need:
YesNo
YesNo
YesNo
YesNo
If yes, describe the type of assistance you need:
YesNo
YesNo
If yes, please provide DRIVEN NeuroRecovery Center with a copy of the report including the doctor’s interpretation.

NOTE: For safety reasons, clients with no bone density assessment or medical report of bone density assessment will be assumed to have osteoporosis. This may place limitations on the exercises used for your exercise program.

Please list all medications you are currently taking including the type, dosage and its function. *

Rows	Medication Name	Dosage (mg/day)	Type (Function)
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10

Use this space to list any additional medications not listed above. Include medication name, dosage (mg/day), and type (function).

Please list your previous and / or current rehabilitation (physical therapy, occupational therapy, etc.) *

Rows	Name of Facility	Location of Facility (City, State)	Duration (in Months)	Results
Rehab 1
Rehab 2
Rehab 3
Rehab 4
Rehab 5

Use this space to list any additional rehabilitation not listed above. Include name of facility, location of facility (City, State), duration (in months), and results.

List your previous or current fitness / wellness regimen (since injury or diagnosis). Include any physical activity you do that would be considered exercise or rehabilitation (i.e. FES bike, Standing Frame, etc.): *

Rows	Activity Type	Duration (Minutes)	Frequency (How Often)
Activity 1
Activity 2
Activity 3
Activity 4
Activity 5

Use this space to list any additional activities not listed above. Include activity type, duration (minutes), and frequency (how often).
Should be Empty:

Medical Statement

Medical Information