Questionnaire

In order to judge the chances of Locomotor (Laufband) Therapy in a specific case detailed information on the extent, nature, etc of the injury is very important.

If you are interested in taking part in such a therapy please answer all of the following questions, which will allow me to judge whether at all you might profit from our new Laufbandtherapy. You may call me after two weeks. Telephone numbers and dates are provided by my secretaries at ++49 228 287 22316. In the positive case usually a personal examination may be arranged in order to allow a valid suggestion. Therapy can currently be performed at a few Rehabilitation Centers indoor (e.g. Karlsbad-Langensteinbach, Germany), duration depends on severeness of injury and ranges from 4 to 16 weeks. An ambulatory service for Laufband Therapy is provided in Bonn.

Dr Anton Wernig, MD

Personalia

Name, first name:

Date of birth:

Address:
Street

ZIP / City:

Telephone / Fax

E-mail:

Cause of injury:

(trauma, tumor, inflammation, vascular, etc)

Date of injury:

Segmental level of injury:

(cervical, thoraic, lumbar)
Amount of spasticity:

(zero, weak, severe, most severe)
Antispastic drugs:

(name and amount per day)

Remaining motor functions when in sitting position:

Hip:
Can you actively lift your thighs: (zero, 5 cm, 10 cm, 20 cm, more)

Left:

Right:

Knee:
Can you actively extend your knee joints: (zero, little, full)

Left:

Right:

Standing/Walking:

Can you stand upright without braces?

(no; yes with help of one person; yes alone)

Can you make steps?

(no; yes with help of two persons; with a walker; with two canes; without canes)

Distance:
(1 m; 5 m; 20 m; more)

In case of tetraplegia:
Can you use your arms/hands to hold canes or a metal frame while standing/walking?

Periods of rehabilitation: (duration, city/name of clinic)
first rehabilitation

subsequent rehabilitations