Cerebral Palsy Record

Person with Cerebral Palsy

National Health Identifier

There are too many characters in this field

First Name *

First name is required There are too many characters in this field

Middle Name

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Last Name *

Last name is required There are too many characters in this field

Date Of Birth *

(DD-MM-YYYY)

Date of Birth is required There are not enough characters in this field There are too many characters in this field The date is invalid

Sex *

Sex is required

First Formal Diagnosed Age

Not a valid number

Type of Cerebral Palsy

Limb

Severity of Cerebral Palsy

Person Responsible

Type of Relationship *

Required

First Name

There are too many characters in this field

Last Name

There are too many characters in this field

(Area Code) Phone

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Health Professional Notifying the Register

Date Register Discussed *

The date is invalid

Type of Professional *

Required

District Health Board *

Required

First Name *

First name is required There are too many characters in this field

Last Name *

Last name is required There are too many characters in this field

Place of Business

There are too many characters in this field

Email *

Email address is invalid