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The Bernstein Approach
 

Cerebral Palsy

Step 2 of 3

Please tell us more about the injured child:

Injured child's first name: required field
Injured child's last name: required field
Address:
City:
State:
Zip:
Area code & phone number:
 - -

Home Work Mobile
Child's name:
Current age:
Gender: Male Female
Child's date of birth:
______________________________

Please tell us about the injured child's birth:
Hospital where child was born:
Hospital location - City:
Hospital location - State:
Treating physician's name:
______________________________

Please tell us more about the injury:
Was child diagnosed with cerebral palsy?

Yes No Unsure
Was child diagnosed with mental retardation?

Yes No Unsure
Were there difficulties during labor?

Yes No Unsure
Did child have signs of physical trauma right after birth?

Yes No Unsure
Was mother treated for infection during pregnancy?

Yes No Unsure
Was child born with an infection?

Yes No Unsure
Did mother have hypertension or diabetes during pregnancy?

Yes No Unsure
Was child born with signs of oxygen deprivation?

Yes No Unsure
______________________________
Are you the current legal guardian of the child?

 Yes No Unsure

required field = Required Why?
 
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