Kwaliteitsstandaard atypische parkinsonismen

Pagina 235 B IJLAGE 12: A ANVRAAG COMPLEX LOOPHULPMIDDEL Patiëntgegevens Naam :___________________________________ Geboortedatum :___________________________________ Adres :___________________________________ Postcode + Woonplaats :___________________________________ Zorgverzekeraar :___________________________________ Polisnummer : ___________________________________ BSN nummer : ___________________________________ Diagnose:  Ziekte van Parkinson  Atypisch Parkinsonisme (bijv. MSA, PSP, Vasculair Parkinsonisme)  anders, nl __________________________________ Relevante nevenpathologie: ___________________________________________________________________ Aard van de balans- belastingsproblemen (wat zijn de functionele beperkingen, bijv. propulsie, festinatie, freezing, handkracht, sensibiliteit, staan, balans, conditie/belastbaarheid, houdingsveranderingen) : __________________________________________________________________________________________ ____________________ ________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____ Reden waarom een standaard loophulpmiddel/rollator niet voldoet (welke standaard loophulpmiddelen zijn uitgeprobeerd, waarom volstaan deze niet) : __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _________________________________________________________________________________________ Functionele pakket van eisen (motivatie gebaseerd op beperkingen, benoem de eisen op basis van de aard van balans- en/of belastingsproblemen) : __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Welke complexe loophulpmiddelen zijn uitgeprobeerd , welke is volgens u de meest adequate oplossing : __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________