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Solutions for Increasing Movement of Weak, Neurologically Impaired Arms

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Patient Information Form

Patient First Name *

Patient Last Name *

Street Address

City

State

Zip/Postal Code

Country

Home Phone *

Mobile Phone

Email Address

Caregiver First Name

Caregiver Last Name

Caregiver Street Address

Caregiver City

Caregiver State

Caregiver Zip Code

Caregiver Country

Caregiver Phone

Caregiver Mobile Phone

Caregiver Email Address

Patient Diagnosis:

Side Affected:

Left
Right
Both

Date of onset:

Current Age:

Caregiver Involvement:

Yes
No

Currently Enrolled in Therapy?

Yes
No

If yes, Name and contact number for therapist:

Can patient bend elbow?

Yes
No

Can patient straighten elbow?

Yes
No

Can patient move hand/fingers?

Yes
No

What is the patient/caregiver's goal in using his/her arm?

Ability to understand directions:

Good
Fair
Poor

Ability to speak:

Good
Fair
Poor

Other medical complications:

Comments/Additional Information:

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myomo Intelligent Stroke Rehab Arm Brace -- Patients & Caregivers

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