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GTA Movement Disorders Team
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Referrer Information
Referral Submitted By:
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Neurologist
Primary Physician
Self-Referral
Other
Referrer's Name
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Referrer's Name *
Referrer's Contact Phone Number
Referrer's Contact Phone Number
If self-referred, please enter 'N/A'.
Referrer's Contact Email
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Referrer's Contact Email *
If self-referred, please enter 'N/A'.
Patient Information
Patient Name
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Patient Name *
Date of Birth
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Date of Birth *
Patient's Contact Phone Number
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Patient's Contact Phone Number *
Patient's Contact Email
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Patient's Contact Email *
Movement Disorder Diagnosis
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Movement Disorder Diagnosis *
Relevant Medical History
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Relevant Medical History *
Services
Physiotherapy
Please check all that apply
Falls
Posture
Exercise Program
Pain
Gait and Balance Impairments
Speech and Language Therapy
Please check all that apply
Speech Clarity
Voice Volume
Cognitive Communication (i.e. word-finding, verbal memory)
Swallowing
Dietetics
Please check all that apply
Weight Management
Medication/Protein Interaction
Constipation
Blood Pressure Management (i.e. orthostatic hypotension)
Other Symptom Management (i.e. heartburn, nausea):
General Healthy Eating Education
Occupational Therapy
Please check all that apply
Cognitive Strategies
Adaptive strategies for fine motor difficulties (i.e. eating, dressing, writing):
Additional Information
Additional Information
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