CLICK HERE to pick your choice
of Outreach City/Day:
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REQUIRED |
What is Your Diagnosis?
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REQUIRED
which side?
Foot Drop patients - Dr. Nath can only help you if you
are within six months of the onset of the foot drop
.
NF or Nerve Tumor patients are only seen at
Dr. Nath's main office in
Houston.
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If your injury was birth related - check which applies to you:
Was there shoulder dystocia?
Were forceps used for this birth?
Was a vacuum extractor used for this birth?
Was there a c-section performed?
Was there Horner's Syndrome (droopy eye)?
Birth Weight
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FIRST Name of Patient
REQUIRED |
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LAST Name of Patient
REQUIRED |
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Date of Birth & Age
REQUIRED |
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Parents' Names
REQUIRED (if under 18) |
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Address Line One
REQUIRED |
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Address Line Two
City/State/Zip or Country
REQUIRED |
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Computer Access ?
Regular Email Access? |
YES,
I have computer access and I check my emails frequently. I will watch
this site for updates about this Outreach event and look forward to
receiving emails concerning this event. I
understand that my appointment
will be emailed to me approximately 1-2
weeks prior to the Outreach date.
NO, I
do not check my emails frequently or I do not have regular computer
access. Please call me with information about the Outreach event and to
give me my appointment time. |
| Injury History |
Please describe how the injury occurred, when
it occurred and how old you were at the time. <maximum two lines>
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Current Additional Therapies
Select only the things that you are
currently involved in - not activities
that you once did some time ago.
For example:
If you did serial casting 3 years ago,
then do NOT check mark it.
But if you are doing it this month,
then checkmark it.
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SURGERY HISTORY - please list only the related surgeries you've had for your peripheral nerve issue.
List surgeries done by Dr. Nath and by other physicians as well.
PLEASE FILL THIS IN COMPLETELY - EVEN IF YOU ARE ALREADY A PATIENT OF DR. NATH
Dr. Nath cannot bring his office files to an Outreach Day, so we need this information
to create a file
for your appointment.
ABREVIATIONS: (if your surgery is not listed here, don't worry - just put a short name below and then
describe it further down where there is more space.)
PR = primary
NT = nerve transfer
MQ = mod quad
TT = triangle tilt
HO = humeral osteotomy
FO = forearm osteotomy
MT/RT = muscle/tendon releases/transfers
CTR = carpal tunnel release |
IL = Ilizarov procedure
FGT = forearm gracillis transfer
BTL = biceps tendon lengthening
CAPS = shoulder capsulodesis
WCAPS = wrist capsulodesis
ACR = anterior capsule release
Acromio = acromioplasty
Other = please describe
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REQUIRED
Surgical Procedure 1
Age or Year
Surgical Procedure 2
Age or Year
Surgical Procedure 3
Age or Year
Surgical Procedure 4
Age or Year
Surgical Procedure 5
Age or Year
Surgical Procedure 6
Age or Year
Surgical Procedure 7
Age or Year
Surgical Procedure 8
Age or Year
Are you an existing patient or a new patient? And Is there any additional information
you'd like to add about your surgeries or questions
for Dr. Nath
?
<maximum two lines please >
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Appointment Preference
For some Outreach Days, adults are
seen the evening before. Please check
with the coordinator before you make
your travel plans.
Do not purchase air tickets unless you
check with the coordinator first to make
sure that the Outreach Day is still going
to happen. Some events are cancelled
as a result of low number of registrations.
tnpiclinics@gmail.com (215) 643-5913 EST |
Morning
Afternoon
Here is my flight information:
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| Note To Outreach Coordinator |
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Please note that there is never a charge to see Dr. Nath during an Outreach event.
However, there is a charge if you were to have surgery.
Please
check your emails frequently for updates and for notice when the
appointments are posted and especially the week before the event.
Appointments will be posted on this site approximately two weeks before the Outreach Day.
Clinic Coordinator can be reached at tnpiclinics@gmail.com or (215) 643-5913 EST - U.S.A. |
