Brachial Plexus Palsy Center

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