Patient Information Form
Thank you for your interest in the St. Louis Children's Hospital Cerebral Palsy Spasticity program. For security reasons, the form will time-out after 10 minutes. Please have the following information available to you so you may fill out the form within the time constraints. If you have any problems with the form or cannot complete it in 10 minutes, please call us at 314.454.2813 or toll-free 800.416.9956.
Information to have on-hand
- Gestational age at birth
- Birth weight
- Age when diagnosed
- Dates and types of all orthopedic surgeries
- Date of most recent Botox injections
- Date of most recent hip x-rays
- If your child had an MRI, and, if so, the age at which this was done
The last question on the form asks you to choose whether you would like to schedule an appointment or a video evaluation.
- If you choose an appointment , that means that you would come to St. Louis for an appointment, and if surgery is recommended, you would schedule surgery for a later date.
- If you choose video evaluation, that means that once the video and other requested information is reviewed and surgery is recommended, you could schedule the initial evaluation and surgery during the same week.
- Please keep in mind that it is possible that Dr. Park may need to see the patient in the clinic prior to scheduling surgery. If that is the case, evaluation and surgery cannot be done in the same week.