SCI-FIT - Spinal Cord Injury Functional Integrated Therapy

In an effort to provide the most safe and effective program, it is necessary for all clients to complete this application in its entirety. All information provided will remain confidential. If the client is under the age of 18, a parent or guardian must sign the application.

Personal Information

LEGAL NAME:
Are you applying for a   trial week?   permanent client position?       Possible start date  
Birthdate     E-mail Address
How did you hear about us?
Permanent Home Address:
If mailing address is different from above, click here.
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 Injury: / /    Level of injury
Cause of Injury:  
Complete    Incomplete      Asia Score:
Current Therapy? Yes    No

Hospitalization since injury:
   
Type of wheelchair: Manual    Electric    Power Assisted/Manual
Assistive standing/walking device:
Yes
No
Hospitalization of initial trauma:
Length of Stay:
From  
To      
Location of rehabilitation:
Length of Stay:
From  
To      
Please list all current medications:
     
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
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 that have normal sensation below level of injury:
Briefly describe areas that have little to no sensation below level of injury:
Briefly describe muscles that have normal movement below level of injury:
Briefly describe muscles that have weakness to no movement below level of injury:
Any spasms? Yes    No

Any pain? Yes    No

Any Autonomic Dysreflexia? Yes    No

History of Urinary Tract Infections? Yes    No

History of Pressure Sores/Skin Breakdowns? Yes    No

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

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

To become a client of SCI-FIT, one must meet the following criteria:
  • Spinal Cord Injury at any level as long as the individual can breathe without the use of a machine
  • Cleared by a physician to participate in an intense exercise therapy program
  • 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 post-injury)
I have completed this application to the best of my knowledge in an effort to make known any medical conditions that may limit my participation in SCI-FIT. I further understand that SCI-FIT has the right to terminate my program at any time.   I AGREE

SCI-FIT: Are you ready?