Amtryke Assessment Form

Name:  
Home Address:
City:   State:   Zip:
Home Phone:  
E-Mail Address: (required)
Age:    Weight:lbs    Height:
Child Ambulatory:   With Assistance:    Non-Ambulatory:
Disability or Special Consideration, Leg length discrepancy:
Desired Goal or Outcome:
Arm Length
(axilla to finger tip):		    Right:     Left:
Leg Length
(inner groin to 
bottom of feet):		     Right:     Left:
Head Control:      Poor    Fair  Normal
Trunk Control:      Poor    Fair  Normal
Hand Control:      Poor    Fair  Normal
Tone:      Low    High  Normal
Will there be periodic therapist follow-up on this child?   Yes  No
Frequency:
Therapist:
Address:
City:   State:   Zip:
Phone:
Does this child have available funding for an AmTryke?    Yes  No
(If yes, please explain):
Does this child need assistance with funding?      Yes  No
Where did you first learn about AmTryke?


Home | Info | Programs | AmTryke® | Scholars
Leader Fax | Big Hat | Friends | New Clubs | Directory
Message Board | Reports/Forms | Store | Contact Us

Copyright © 2005 National AMBUCS™, Inc.
4285 Regency Court, High Point, NC 27265
Phone: (336) 852-0052 Fax: (336)852-6830
E-Mail: [email protected]
Web Page: http://ambucs.org

Recommended Browser : IE 5.0 or Netscape 4.7
Plugins : Flash 4.0 and Adobe Acrobat 4.0