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.
SUBMIT
Name and surname:
Required
Thank you!
Your application form has been sent
1. Patient data
Required
Date of birth:
Required
Birth certificate No.:
Required
Diagnosis:
Required
Date of the last diagnosis:
Required
Health insurance company:
Required
Height of the patient:
Required
Weight of the patient:
Required
Size of shoes:
Required
Underwent surgeries:
Required
2. Parents/accompanying person data:
Name and surname:
Required
Date of birth:
Required
State:
:
Required
Permanent address:
Required
Mailing address:
Required
Phone number:
Required
E-mail:
Required
We need accommodation
during the rehabilitation stay:
Required
3. Health condition of the patient:
Patient has metals inside his or her body:
Required
Patient underwent chemotherapy or radiation therapy:
Required
Patient is taking immunosuppressants:
Required
Patient has osteoporosis:
Required
Patient’s chronic treatment
has been changed recently:
Required
The patient has an EMG or genetically confirmed muscular disease:
Required
Epilepsy:
Number of seizures during one month:
Required
Current medication:
Required
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:
Required
Scoliosis:
Required
Lordosis:
Required
Tracheostomy:
Required
Diabetes:
Required
Hydrocephalus:
Required
Shunts:
Required
Motoric abilities
Turning over:
Required
Crawling:
Required
Sitting:
Required
Standing up:
Required
Walking:
Required
Used aids (e.g. wheelchair, crutches etc.):
Required
Currently used drugs and reason of usage:
Required
Allergies:
Required
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:
Required
Signature:
Required
Thank you in advance. We are looking forward to your visit!
