CHOOSE ONE OPTION:

What is Your Diagnosis?


which side?

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

   
FIRST Name of Patient...............................................
LAST Name of Patient................................................
Date of Birth & Age...................................................
Parents' Names.........................................................
Address.....................................................................
City/State/Zip or Country.........................................
Home Telephone......................................................
Cell.............................................................................
Main Email REQUIRED..............................................
Secondary Email.......................................................
Date of Injury & Reason for Injury
(for traumatic bpi, winging scapula and foot drop)

   

Current Additional Therapies

Select only the things that you are
currently involved in - not activities
that you once did some time ago
.

 

 

 

  • Daily Rom
  • Daily Stretching
  • Physical Therapy
  • Occupational Therapy
  • TES Nighttime Stim
  • NMES Daytime Stim
  • Biofeedback
  • Nighttime Splinting
  • Daytime Splinting
  • SARO Splint
  • TheraTogs
  • Kinesiotaping
  • Serial Casting
  • Dynamic Splinting
  • Aquatic Therapy
  • Hippotherapy
  • Massage Therapy
  • Botox

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

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
M Rel = muscle release
M Trfr
= muscle /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

 

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?


 

BY HITTING THE "I AGREE" BUTTON, YOU ARE LETTING US KNOW THAT YOU HAVE INTENTION TO COME TO YOUR APPOINTMENT AND THAT YOU HAVE READ, UNDERSTOOD AND AGREE TO THE FOLLOWING CONDITIONS AS NOTED BY DR. NATH.

Please note that Dr. Nath makes no statement, guarantee or warrantee of any type that he can diagnose or treat your medical or other condition. Dr. Nath makes no statement, guarantee or warrantee that he will accept you as a patient. This is important because you may travel long distances and undergo considerable expense to attend an outreach event and Dr. Nath may not be able to help you, diagnose or treat you. Dr. Nath is not responsible for any inconvenience, expense or travel arrangements that you make to see him. You should ALWAYS attempt to have local caregivers manage your medical problems if possible. Please note also that Dr. Nath makes every attempt to be at scheduled events on time and on the dates scheduled. However, many unforeseen circumstances can and do arise that will alter any plans that are made. Dr. Nath regrets any inconveniences that may be caused if last-minute cancellations or alterations occur in his schedule and he hopes you will be understanding if this happens. No statement, guarantee or warranty of any type is implied by having a scheduled visit made and the visit may be canceled for any reason. Again, Dr. Nath is not responsible for any inconvenience, expense, work loss or travel arrangements that are affected by outreach event cancellation or because he cannot diagnose or treat you or because he does not accept you as a patient.

Please do not purchase any airline tickets until the date of the outreach event has been confirmed.

If you are flying in to see Dr. Nath, we highly recommend that you purchase flight cancellation insurance that would cover you in case Dr. Nath's schedule changes or if an emergency arises on either side.

Minors must be registered by their parent or legal guardian.
We will not accept a registration done by a third party.

Minors must be accompanied by their parent or legal guardian.