Assessment Application

Assessment Application

Parkinson ’s disease

Moreton Eye

Leominster

Herefordshire

HR6 0DP

Tel: 01568 616179

Email:

‘A pathway towards Independence’

Registered Charity Number 1141827

Contents

Application Form

• Personal details
• Medical details
• Present state of movement
• Current treatment
• Declaration
• Photographic permission form

Personal Details

Name:
Date of birth:
Home address:
Home telephone number:
Mobile telephone number:
Email:
Emergency contact name:
Relationship
Emergency contact number:
Mobile:
Work:

Medical Details

GP’s name
GP’s address
Diagnosis
Date of diagnosis
The first indication of your condition:
Which side is more affected?
Drug Regime (if applicable)
General Health
Any other drugs taken (please provide details)
Any Allergies?
Operations? Please provide details
Vision
Hearing

PresentState of Movement

Have you got any difficulties with the following:
Speech (volume, clarity)
Facial expressions
Swallowing
Tremor (details)
Handwriting (size, fluency)
Rigidity (where)
Dyskenesia (where)
Balance
Falling over (how often)
Rolling over in bed
Getting in and out of bed
Sleeping
Getting up from the floor
Sitting down
Standing up from a chair
Walking
Freezing (how often)
Eating
Drinking
Un/Dressing (zips/buttons)
Everyday Chores
Any other

Current Treatment

Neurologist
Name
Address
Frequency
PD Nurse
Name
Address
Frequency
Physiotherapy
Name
Address
Frequency / Duration
Speech/Language Therapy
Name
Address
Frequency / Duration
Occupational Therapy
Name
Address
Frequency / Duration

Declaration

I declare that
All the information above is true and to my best knowledge
I will inform all relevant professionals that I will participate in Conductive Education
Name
Signature
Date

Photographic Permission Form

Throughout the sessions we would like to photograph and maybe video you. The photographs are displayed in your development file and can be viewed at any time.
We would also like to use these materials for teaching, educational and promotional purposes including on the website –
To enable us to photograph or video you it is good practice to seek permission. We would appreciate it if you could sign this form and return it to us.
I give permission to be photographed and filmed at Megan Baker House for the following purposes:
Please tick
Progress reports and your files –
often shared with school and other professionals
Teaching / training materials
Newsletter
Website
Other promotional materials –
leaflets, posters, fundraising presentations etc
Comments:
Name
Signature
Date
Conductors signature
Date
CC to Latona

Thank you