Participants Application & Health History
Email address *
Name: *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Height *
Your answer
Weight *
Your answer
Address *
Your answer
Phone number *
Your answer
I can receive text messages at the above number *
Parent or legal guardian *
Your answer
Emergency contact *
Your answer
Emergency contact phone number *
Your answer
Referral source
Your answer
How did you hear about our program
Your answer
Diagnosis
Your answer
Date of onset
MM
/
DD
/
YYYY
Please indicate current or past special needs in the following areas *
Yes
No
Column 3
Vision
Hearing
Sensation
Communication
Communication Devise
Heart
Breathing
Elimination
Circulation
Emotional/Mental Health
Behavioral
Bone/joint
Muscular
Thinking/cognition
Allergies
Please add comments for any yes answers above *
Your answer
MEDICATIONS (Include prescription, over-the-counter, name, dose and frequency: *
Your answer
Describe your abilities/difficulties in the following areas (include assistance required or equipment needed)
Your answer
PHYSICAL FUNCTION (i.e. mobility skills such as transfers, walking, wheelchair use, driving/bus riding)
Your answer
PSYCHO/SOCIAL FUNCTION (i.e. work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.)
Your answer
If emotional breakdowns are a possibility, what would you suggest to help?
Your answer
GOALS (i.e. shy are you applying for participation? What would you like to accomplish?
Your answer
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