SCI-FIT Online Application

Personal Information

LEGAL NAME:

Are you applying for a   trial week?   permanent client position?       Possible start date   MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2011 2012

Birthdate MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940     E-mail Address

How did you hear about us?

Permanent Home Address:
If mailing address is different from above, click here. Mailing Address: (from MM 01 02 03 04 05 06 07 08 09 10 11 12 / YYYY 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 to MM 01 02 03 04 05 06 07 08 09 10 11 12 / YYYY 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 ) Remove Mailing Address

Phone at Mailing Address (with area code): Permanent home phone (with area code):       Cell phone (with area code):

In case of emergency, please notify:     Phone (with area code):

Medical Information

Height:      Weight:

Date of Onset: MM 01 02 03 04 05 06 07 08 09 10 11 12 / DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970    Neurological Disorder: Choose One Brain Injury CP MS Parkinson's SCI Spinal Tumor Stroke Transverse Myelitis Other

Cause of Injury:   Level of Injury:       Complete    Incomplete      Asia Score: What type?   Please describe:

Current Therapy? Yes    No Where? Type/Frequency:

Hospitalization since injury:     add another +     add another +     add another +

Type of wheelchair: Manual    Electric    Power Assisted/Manual

Assistive standing/walking device:
Yes
No

Hospitalization of initial onset (if any): Length of Stay: From   MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 To       MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970

Location of rehabilitation: Length of Stay: From   MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 To       MM 01 02 03 04 05 06 07 08 09 10 11 12 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970

Please list all current medications:       add another +       add another +       add another +       add another +       add another +       add another +

Please answer Yes or No to the following. Indicate "Yes" for those that apply to you at present or have applied to you in the past:
History of chest pain:	Yes    No
History of heart disease or any other heart/valve disorder:	Yes    No
Any chronic illness or condition:	Yes    No
High Blood Pressure:	Yes    No
Low Blood Pressure:	Yes    No
Difficulty with physical exercise:	Yes    No
History of pathological fracture:	Yes    No
Pregnancy (now or within the last 3 months):	Yes    No
Breathing/Lung Problems (Asthma):	Yes    No
Any other disease of the lungs:	Yes    No
Muscle, joint or back disorder, or any previous injury still affecting you:	Yes    No
Please explain:
Diabetes:	Yes    No
Thyroid condition:	Yes    No
High Cholesterol:	Yes    No
Obesity:	Yes    No
Hernia, or any condition that may be aggravated by intense exercise:	Yes    No
Has your doctor cleared you to participate in an intense exercise program?	Yes    No
A physican's release is required to participate in SCI-FIT. * Please check if you understand this policy

Sensory and Motor Conditions

Briefly describe areas of the body that have normal sensation, or are not affected by your condition:

Briefly describe the areas of the body that have little or no sensation, or are severely affected by your condition:

Briefly describe areas of the body where motor control is normal, or not affected by your condition:

Briefly describe areas of the body that have little to no motor control, or are severly affected by your disorder:

Any spasticity? Yes    No If Yes, briefly explain:

Any tone? Yes    No If Yes, briefly explain:

Any pain? Yes    No If Yes, briefly explain:

Any Autonomic Dysreflexia? Yes    No If Yes, briefly explain symptoms:

History of Urinary Tract Infections? Yes    No Most recent:

History of Pressure Sores/Skin Breakdowns? Yes    No If Yes, briefly explain what area: Please understand that it is your responsibility to notify SCI-FIT of any skin irritations/possible pressure sores. * Please check if you understand this policy

Any Heterotrophic Ossification? Yes    No Location:

Have you been diagnosed with Osteoporosis/Osteopenia? Yes    No SCI-FIT requires you to obtain a bone scan if you are more than one year post injury. * Please check if you understand this policy

Deep Vein Thrombosis? Never    Past    Present

Do you have Bladder/Bowel control? Yes    No

What are your goals and / or health concerns for coming to SCI-FIT?

What experiences have you had with alternative medicine (acupuncture, massage, etc.)?

Qualifications

All neurological disorders will be assessed on a case-by-case basis. The primary qualifications that must be met in order to become a client at SCI-FIT are the following:

• The client must possess some level of cognitive function (intellectual process by which one becomes aware of, perceives, or comprehends ideas, and involving all aspects of perception, thinking, reasoning, and remembering).
• Client must be cleared by a physician to participate in an intense exercise therapy program
• Client must be cleared by a physician to perform weight-bearing activities through the upper and lower extremities (a bone scan will be required for those 1 or more years in a wheelchair or non-load bearing environment)
• Client must possess a positive attitude and willingness to work hard