Patient Referral

To refer a patient to the Brachial Plexus Center, parents and physicians may contact:

Brachial Plexus Center
St. Louis Children's Hospital, Ste. 4S 20
One Children's Place
St. Louis, MO 63110

Phone: 314-454-2811
Fax: 314-454-2818
Toll Free: 800-416-9956
Email: park@wustl.edu

 

Or you may complete this Initial Evaluation form online.
* denotes required fields

Patient Information
* Person submitting form
* Email
* Patient's name
Patient's address
* Patient's telephone number
Parent's name
Parent's address
Parent's telephone number
Date of visit
Date of birth
Sex	Male   Female
Race	W   B   Other
Primary physician or pediatrician
Neurologist or neurosurgeon
Physical or occupational therapist
History
Maternal age	years
Gestational age at birth	weeks
Labor time in hours	hours
Labor	difficult   normal
Presentation	head   breech
Delivery	Vaginal delivery   Forceps used yes   no Suction used yes   no Caesarian section
Birth	single baby  multiple babies
Birth weight	pounds   ounces
Apgar score	1 min   5 min
Fractured clavicle
Fractured arm
When were arm improvements first noticed?
Prior CT, MRI or x-rays? Where:
When:
Muscle strength at the time of this referral
Parents may need assistance from the physician or therapist in filling out this form. (Note: Grade the best strength observed during evaluation.) 1: No or trace muscle contraction 2: Muscle contraction without gravity 3: Muscle contraction against gravity 4: Muscle contraction against resistance NG: Not graded due to difficulties Strength Muscle 1 2 3 4 NG Deltoid Biceps Triceps Wrist flexors Wrist extensors Finger flexors Finger extensors