Selective Dorsal Rhizotomy - Family Survey on Patient Education Materials

1. Background Information

 
1. What is the age of your CHILD?
2. What is the gender of your CHILD?
3. What is your child's diagnosis(es)? Check ALL that apply.
4. Has your CHILD had previous hospital stays? If yes, what hospital(s) did your child stay at?
5. Has your CHILD had previous surgeries? If yes, what hospital(s) did your child have a prior surgery?
6. Does your child currently attend outpatient therapies/services?
7. Prior to this hospital stay, how recent has your child attended outpatient therapies/services?
Within past 2 monthsWithin past 6 monthsWithin past 12 months
OT
PT
Speech
Psychology
Therapeutic Recreation
School (therapies)