New Patient Supporting Documents for the Center for Gait & Movement Analysis

Diagnosis /Symptom: Cerebral Palsy

What should the referring provider send?

1. Reason for referral
   What are the concerns regarding gait pattern and related functional activities
   What is your goal for this visit? What information do you want from CGMA?
   What is family’s concern about child’s gait.
2. How far can the child walk? Does the child wear orthotics or use an assistive device?
3. Medications, especially for spasticity, dystonia or other movement disorders; seizure meds
4. Medical records regarding relevant evaluation and treatment related to CP, especially injections (botox, phenol), orthopedic surgery, neurosurgery, PT, orthotics and other assistive devices
5. Relevant imaging, e.g. hip/pelvis, spine, feet, leg length X-rays; MRI or CT of brain or spinal cord
6. Relevant laboratory reports
7. Behavioral, sensory or cognitive issues that may make it difficult for child to tolerate a gait analysis with surface EMGs and reflective markers

Diagnosis /Symptom: Gait abnormality, usually children without diagnosis

What should the referring provider send?

1. Reason for referral
   What is your goal for this visit?
   What information do you want from CGMA?
   What are the family’s concerns?
2. Concerns regarding gait pattern and related functional activities, e.g. toe walking, feet turning in or out, genu valgus or varus (knock knees or bowlegs), flat feet, tripping, poor coordination
3. Is child over 18 months and not yet walking? When did the child begin walking?
4. Prenatal, birth and developmental history
5. Medical and surgical history including physical therapy
6. Relevant imaging, e.g. hip, spine, feet X-rays; CT, MRI
7. Orthotics and assistive devices

Diagnosis /Symptom: Miscellaneous diagnoses with gait abnormality (e.g. stroke, Parkinsons, MS, traumatic injury), often adolescents or adults

What should the referring provider send?

1. Reason for referral
   What is your goal for this visit?
   What information do you want from CGMA?
   Concerns regarding gait pattern and related functional activities
   Patient’s or family’s concerns about individual’s gait.
2. Diagnosis
3. How far can the individual walk? Does the individual use an assistive device (e.g. walker), orthotics, prosthetics, etc?
4. Medical records regarding relevant evaluation and treatment related to diagnosis and gait problems, especially injections (botox, phenol), orthopedic surgery, neurosurgery, PT, orthotics, prosthetics, assistive devices
5. Relevant imaging, e.g. X-ray, CT, MRI
6. Relevant laboratory reports
7. Medications