| PATIENT:_________________________________________________ | |||
| SOCIAL SECURITY #:_______________________________________ | |||
| DATE OF BIRTH:____________________________________________________ | |||
To the Doctor: Please complete the following report attaching copies of lab reports. Please use the back of the form if additional space is needed. |
1. | When was the patient last examined? _________________ |
| 2. | How old was patient when polio was diagnosed? _______________ |
| 3. | What symptoms did patient display at the time polio was first diagnosed? |
| 4. | What treatment did patient receive at the time of diagnosis? |
| 5. | What, if any, follow up care was provided? |
| 6. | What are the residual impairments, if any, from the first polio bout? |
| 7. | What symptoms brought the patient to you? |
| 8. | What symptoms is the patient currently displaying? |
| 9. | How did the patient's current symptoms relate to the earlier diagnosis of polio? |
| 10. | What treatment is the patient currently receiving? |
| 11. | Please describe the short and long term prognosis for the patient. |
| 12. | Please complete attached Residual Functional Capacity Report in light of patient's present condition. |
| 13. | What restrictions of life style or daily living have been recommended? |
| 14. | From what other medical or psychological conditions does the patient suffer in addition to those described above? |
| Date Report Completed: | ______________________________ |
| Signature of Physician: | ______________________________ |
| Physician Name: | ______________________________ |
| Address: | ______________________________ |
| Telephone: | ______________________________ |
| Specialty: | ______________________________ |