Children’s Program Questionnaire
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1
Step 1
Submission
Child Information Sheet
Last name
your full last name
First Name
your full name
Type of MPS
Date of Birth
date_range
Special Requests
EET
Diet
Diet
Diet
Fish
Meat
Vegetarian
Vegan
Halal
Gluten free
Other
Intolerances / Allergies
0
/
Pureed Food
0
/
PEG Tube
0
/
Eating Behaviour
0
/
Favourite Foods
0
/
Foods Disliked
0
/
Swallowing Difficulties
0
/
Mobility (assistive devices if applicable)
0
/
Needs of the MPS Patient
0
/
Epileptic Seizures
0
/
Urinary / Fecal Incontinence
0
/
Gait Instability Incontinence
0
/
Restlessness / Hyperactivity
0
/
Shortness of Breath / Respiratory Distress (assistive devices if applicable)
0
/
Shortness of Breath / Respiratory Distress (assistive devices if applicable)
0
/
Tracheostomy
0
/
Other Limitations
0
/
Current Complaints
0
/
Child’s Favourite Activities
0
/
What the Child Dislikes
0
/
Best Way to Calm the Child
0
/
Hearing Aid
0
/
Glasses
0
/
Back Brace / Corset
0
/
Any other information that will assist with the care of your Child
0
/
Parents’ Phone Number
0
/
Parents email
0
/
Other emergency contact.
0
/
Submit
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