Evaluation

Step 1

Create video as this one &
Sent on info@adkanellopoulos.eu or helpdesk@adkanellopoulos.eu

Step 2

Send us your HIP X RAY photos &
Sent on info@adkanellopoulos.eu or helpdesk@adkanellopoulos.eu

Step 3

Complete the following questionnaire

SPML EVALUATION

Information Packet for SPML Procedure

Thank you for your inquiry. Enclosed please find the patient questionnaire and other information. You can return the completed forms to the clinic by email.
The email address is info@adkanellopoulos.eu + helpdesk@adkanellopoulos.eu

Once the completed forms, videos and the X-Rays have been received, our office will arrange for a zoom conference

If you have any questions, please call:

(+30) 210-6100888

info@adkanellopoulos.eu

helpdesk@adkanellopoulos.eu

Patient Questionnaire

Name

DOB

Email address *

City, State

Referred by

Physical Therapist

Physical Therapist phone

Is the child able to walk?

If so, can the child walk 20 feet or more in a clinic with or without equipment?

Can the child stand for one minute without assistance?

Does the child use a wheelchair for mobility?

Date

What name does the patient go by?

What is the patient’s overall condition? (example:cerebral palsy, anoxic brain injury, etc.)

Reason for seeing Dr. Kanellopoulos (example: “tight hamstrings”, “walking on toes”)

History of Present Illness (Provide a brief description of the patient’s current problem you are seeking medical attention for):

Child's favorite thing (What does he/she like to play with)/what interests them?)

Birth history (How many weeks was the baby born at? Was there any problem when the baby was in the womb?)

Brain history (Does the patient have cerebral palsy or some other brain disorder? Was this diagnosed with an MRI?):

Any history of Botox injections? (if so, how long have they been getting them and what part of the body was injected?)

Does the patient have Ankle Foot Orthotics (AFO’s)?

Functional Mobility Scale (FMS)

Please read the following questions and fill the boxes with the rating (see below) that best represents your child’s mobility method:

(5 metres, 50 metres, 500 metres)

Rating:
N= Does not apply: e.g., child does not complete the distance.
C= Crawling: child crawls for mobility at home (5 m).
1= Uses wheelchair: may stand for transfers, may do some stepping supported by another person or
using a walker/frame.
2= Uses a walker or frame: without help from another person.
3= Uses crutches: without help from another person.
4= Uses one crouch or one or two single point sticks: without help from another person.
5= Independent on level surfaces: Does not use walking aids or need help from another person.*
Requires a rail for stairs. *If uses furniture, walls, fences, shop fronts for support, please use 4 as
the appropriate description.
6= Independent on all surfaces: Does not use any walking aids or need any help from another person when walking over all surfaces including uneven ground, curbs etc. and in a crowded environment.