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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.

Name and surname:

1. Patient data

Male

Female

Date of birth:

Birth certificate No.:

Diagnosis:

Date of the last diagnosis:

Health insurance company:

Height of the patient:

Weight of the patient:

Size of shoes:

Underwent surgeries:

2. Parents/accompanying person data:

Name and surname:

Date of birth:

State:

:

Permanent address:

Mailing address:

Phone number:

E-mail:

We need accommodation
during the rehabilitation stay:

Yes

No

3. Health condition of the patient:

Patient has metals inside his or her body:

Yes

No

Patient underwent chemotherapy or radiation therapy:

Yes

No

Patient is taking immunosuppressants:

Yes

No

Patient has osteoporosis:

Yes

No

Patient’s chronic treatment
has been changed recently:

Yes

No

The patient has an EMG or genetically confirmed muscular disease:

Yes

No

Epilepsy:

Number of seizures during one month:

Current medication:

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

Scoliosis:

Yes

No

Lordosis:

Yes

No

Tracheostomy:

Yes

No

Diabetes:

Yes

No

Hydrocephalus:

Yes

No

Shunts:

Yes

No

Motoric abilities

Turning over:

Yes

No

Crawling:

Yes

No

Sitting:

Yes

No

Standing up:

Yes

No

Walking:

Yes

No

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

Currently used drugs and reason of usage:

Allergies:

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:

Signature:

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