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GENERAL INFORMATION |
| Participants Name |
* |
| Describe Your Diagnosis/Disability |
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| Parent/Caregiver Name
(if applicable) |
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Date of Birth |
Sex
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Age |
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Height |
Weight
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*DUE TO MANUFACTURE SAFETY STANDARDS
ADAPTIVE
EQUIPMENT HAS WEIGHT LIMITATIONS |
Which program are
you interested in? |
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Address |
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City & State |
Zip
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Home Phone |
* |
Work Phone |
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Local Phone |
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| E-mail |
*
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Emergency Phone |
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Emergency Contact/Relation |
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MEDICAL INFORMATION: |
| Primary Physician |
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| Physician Phone |
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MOBILITY |
| Independent: |
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Assistance required: |
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GENERAL PHYSICAL CONDITION |
Select One |
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Past Surgical Procedures |
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Medications
(dosage, frequency
& reason for medication):
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Please list any allergies |
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Seizures |
If yes, controlled with medications
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If yes, please list medication |
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Type of Seizures |
Date & Length of Last Seizure
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Describe Your SWIMMING Ability |
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Describe Your Past
Canoe/Kayak Experiences: |
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For Horseback Riding:
Describe Your Riding Ability/Experiences: |
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MOTOR STATUS |
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Please select any difficulties with the following: |
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MUSCLE TONE |
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LOSS OF SENSATION |
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DECREASE OF STRENGTH |
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LIMBS |
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SPASTICITY |
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BALANCE |
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CIRCULATION IN RANGE OF MOTION
(The ability to flex trunk, extremities, and rotate head)
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Misc Info |
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SECONDARY PROBLEMS |
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Diabetes |
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Vision Loss |
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Hearing Loss |
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Hearing Aid:
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Bladder Management: Self-Catheterization
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- Leg Bag:
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- Other
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Do you suffer from chronic pain? |
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If YES, list area affected: |
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How is your endurance? |
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Does it decrease with activity? |
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GENERAL ATTITUDE
& BEHAVIOR:
1. NORMAL:
NO PROBLEMS
2. MILD PROBLEMS: INTERFERES SOMETIMES
3. MODERATE PROBLEM: INTERFERES
FREQUENTLY
4. SEVERE PROBLEM: INTERFERES CONSTANTLY |
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COMMUNICATION & PROCESSING: |
Distractibility
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Confusion
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Problem Solving
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Recall / Memory
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Dyslexia
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Disorientation
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Ability to Follow Directions |
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BEHAVIORAL & GENERAL ATTITUDES: |
Self Esteem |
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Self Control
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Motivation |
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Goals
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Anxiety |
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Frustration Tolerance
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Anger |
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Temper
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Impulsiveness |
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Self pity |
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Spatial Disorientation
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Slowness of Speech
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Ability to Self-Correct
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Hostility
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Follow Directions
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Slowness of Cognitive
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ACTIVITIES & SPORTS INVOLVEMENT: |
Swimming |
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Weights |
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Running |
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Soccer |
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Sailing |
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Climbing |
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| Basketball |
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Tennis |
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Archery |
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Biking |
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Water Skiing |
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Walking |
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Gymnastics |
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Rollerblading |
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Ice skating |
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Other |
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How did you learn
about our program? |
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Previous ski/snowboard experience |
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Did you ski prior to your accident? |
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Select one |
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Approximate number of times |
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Type |
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Your goals regarding the ski season |
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Sit Down Skiers
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If you have never skied before and are a potential sit-down skier, please read the paragraph below and answer the questions that follow.
To get up the hill, all skiers use the chairlift. As a sit-down skier, you will ride the lift in your mono, bi or sit down ski and will, with assistance, unload the lift by dropping down as much as 3 feet into the loading ramp. In this unloading process, your hips and back must be able to sustain the jolt or jarring that will occur. Also, in learning to sit-ski you will be taught how to rollover on your side and shoulders as a method of stopping. To do this you will be moving and will make the equipment "tip over". In this case, your arms, shoulders and back must be able to sustain the jolting or jarring that will occur. If you think either unloading or tipping onto your sides may cause you pain or injury, please consult with your doctor before attempting to mono, bi or sit ski and bring a doctor's written release with you.
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Will rolling sideways onto your shoulders cause pain or injury to your back or shoulders, or cause dizziness? |
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Using arm strength, can you push your own wheelchair independently? |
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Within the past six months, have you had any injury to, or surgery on your back, spinal cord or hips? |
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Do you wear a back brace? |
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If yes, describe brace |
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Do you have Harrington Rods? |
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If yes, lengths of time you've had them |
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Is there any reason to be concerned about the safety of
our staff, volunteers, or other clients due to this client?
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Any other important information that has not been mentioned: |
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Send request to |
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