Pleasanton

3283 Bernal Ave., Suite 105, Pleasanton, CA 94566 (925) 846-1848

Sacramento

2404 Del Paso Road, Sacramento, CA 95835 (916) 928-3736

SCI-FIT Online Application

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:
                                       First                                 Last                       Middle (complete)

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:

                        Number and Street

          City or Town            State               Country                  Zip

If mailing address is different from above, click here.

Phone at Mailing Address (with area code):
                                                                                10-Digit Number
Permanent home phone (with area code):
                                                                             10-Digit Number
Cell phone (with area code):
                                                      10-Digit Number

In case of emergency, please notify:
Phone (with area code):
              Name                          Relationship                                                        10-Digit Number

MEDICAL INFORMATION


Height:       Weight:

Date of Onset: / /       Neurological Disorder:

Current Therapy? Yes     No

Hospitalization since injury:

                           Date                                                        Reason                                                    Location
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Type of wheelchair: Manual     Electric     Power Assisted

Assistive standing/walking device:
Yes     No

                                                         Briefly describe type

                                                         Briefly describe gait

Hospitalization of initial onset (if any):

                                 Name

                               Address

          City or Town            State     Zip
Length of Stay:
From    / /
To        / /

Location of rehabilitation:

                                 Name

                               Address

          City or Town            State     Zip
Length of Stay:
From    / /
To        / /

Please list all current medications:

                    Name                                           Dose                                             Freq                                        Start mo/yr
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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 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

Any tone? 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


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

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