CC Enrollment Form

Contact Information
Name *

First Name Last Name
Date: *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender:

Male Female
Date of Birth: *

Month Day Year
Date
Email: *
example@example.com
Primary Phone Number: *
Type of Primary Phone Number: *

Home Cell Work Use this number for scheduling
Alternate Phone Number:
Type of Alternate Phone Number:

Home Cell Work Use this number for scheduling
Emergency Contact: *
Emergency Contact Relationship: *
Emergency Contact Phone Number: *
What Challenge Center services are you interested in? (Click all the apply) *

Physical Therapy Assisted Fitness Supervised Fitness Caregiver Family Aquatics Group Exercises Balance Class Pre-Exercise Screening CFES Program/Training Caregiver Training Wheelchair Fitting I'm not sure
Who can we thank for referring you to Challenge Center?
What is your primary diagnosis? *
Other diagnosis(es):
Primary Insurance Provider:
Secondary Provider:
Primary Physician (please list full name if known): *
Doctor's Phone Number
Doctor's Fax Number
Doctor's Medical Group/Hospital Affiliation: *
Medical History
Please check all the conditions that you have, or have had: *

High blood pressure / Hypertension Low blood pressure Chest pain / Angina Heart Attack Heart surgery Cardiac Arrythmia Coronary Artery Disease Peripheral Vascular Disease Chronic Venous Thromboemolic Disorder Chronic Heart Failure Angioplasty Palpitation / arrythmia Heart disease Other cardiovascular condition Other arterial or venous surgery Dementia Diabetics Mellitus End-stage Liver Disease Pulmonary Embolism Deep Vein Thrombosis Pacemaker Chronic Alcohol or other Drug Dependence Rheumatoid Arthritis, Lupus, Polyarteritis nodosa, Polymyalgia rheumatic or Polymyositis Stroke HIV / AIDS Cancer Obesity Blood disorder Rash Seizures / Epilepsy Fainting / Blackouts Autoimmune disorder Autonomic Dysreflexia Infection: viral or bacterial GERD Gastrointestinal disease Kidney disease End-stage renal disease requiring dialysis Asthma COPD Chronic Bronchitis Emphysema Pulmonary Fibrosis Pulmonary Hypertension Other lung disease Other organ disease Organ surgery Diabetes Osteopenia / -porosis / fracture High cholesterol Arthritis Depression / anxiety / mood disorder Bipolar Disorder, Major Depressive Disorder, Paranoid Disorder, Schizophrenia, Schizoaffective Disorder Amyotrophic Lateral Sclerosis (ALS) Extensive Paralysis ( i.e. hemiplegia, quadriplegia, paraplegia, monoplegia) Huntington's Disease Multiple Sclerosis Parkinson's Disease Polyneuropathy Spinal Stenosis Spinal Cord Injury Stroke-related neurologic deficit
Allergies (please list all known):
Surgical History

If number of surgeries exceeds available fields please attach an additional list below
Type of Surgical History #1
Surgical History #1 Date:

Month Day Year
Date
Type of Surgical History #2
Surgical History #2 Date:

Month Day Year
Date
Type of Surgical History #3
Surgical History #3 Date:

Month Day Year
Date
Please attach a list of any additional surgeries, including the type of surgery and dates if possible:

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Other Hospitalization(s)

If number of hospitalizations exceeds available fields please attach an additional list below
Other Hospitalization #1 Reason:
Other Hospitalization #1 Date:

Month Day Year
Date
Other Hospitalization #2 Reason:
Other Hospitalization #2 Date:

Month Day Year
Date
Other Hospitalization #3 Reason:
Other Hospitalization #3 Date:

Month Day Year
Date
Please attach a list of any additional other hospitalizations, including the reason and date if possible:

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Previous Rehabilitation

If number of rehabilitation terms exceeds available fields please attach an additional list below
Previous Rehabilitation #1 Location
Previous Rehabilitation #1 Date Start

Month Day Year
Date
Previous Rehabilitation #1 Date End

Month Day Year
Date
Previous Rehabilitation #2 Location
Previous Rehabilitation #2 Date Start

Month Day Year
Date
Previous Rehabilitation #2 Date End

Month Day Year
Date
Previous Rehabilitation #3 Location
Previous Rehabilitation #3 Date Start

Month Day Year
Date
Previous Rehabilitation #3 Date End

Month Day Year
Date
Please attach a list of any additional rehabilitation(s), including locations and dates if possible:

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Medications

If number of medications exceeds available fields please attach an additional list below
Medication #1 Name
Medication #1 Frequency Taken (times a day/week)
Medication #1 is taken for ______?
Medication #2 Name
Medication #2 Frequency Taken (times a day/week)
Medication #2 is taken for ______?
Medication #3 Name
Medication #3 Frequency Taken (times a day/week)
Medication #3 is taken for ______?
Medication #4 Name
Medication #4 Frequency Taken (times a day/week)
Medication #4 is taken for ______?
Medication #5 Name
Medication #5 Frequency Taken (times a day/week)
Medication #5 is taken for ______?
Please attach a list of additional medications taken if available, including the medication name, frequency taken and reason for taking said medication:

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Symptoms
Please check all that you are currently experiencing, or have recently experienced:

Visual disturbance (blindness, double vision, etc.) Hearing loss Fatigue Abnormal sensation Swelling Abnormal bleeding Balance Problems / Falls Shortness of breath Incontinence / Bowel or bladder problems Fever / Chills / Night sweats Sudden weight loss or gain Headaches Dizziness Confusion / Memory loss
Pain

Please answer the following regarding any pain that you are having or have recently had
Pain #1 Location(s):
Intensity of Pain #1 (0 for no pain, 10 for worst pain imaginable)
Type of pain (please check any that apply):

Constant Intermittent Burning Aching Sharp Dull
Pain #2 Location(s):
Intensity of Pain #2 (0 for no pain, 10 for worst pain imaginable)
Type of pain (please check any that apply):

Constant Intermittent Burning Aching Sharp Dull
Pain #3 Location(s):
Intensity of Pain #3 (0 for no pain, 10 for worst pain imaginable)
Type of pain (please check any that apply):

Constant Intermittent Burning Aching Sharp Dull
Physical Impairments
Please list any/all you currently have:

High or Low Tone Poor Coordination Ataxia Hemiplegia Paralysis Limb Loss Weakness Shortness of breath Angina Arrhythmia Poor endurance Numbness Contracture
Activities of Daily Living

Please mark the activities that your physical impairment(s) substantially limits or prevents you from accomplishing i.e. which activities can you NOT do without the assistance of another person?
Toileting *

Does not require assistance Assistance required
Bathing/Showering *

Does not require assistance Assistance required
Eating *

Does not require assistance Assistance required
Dressing *

Does not require assistance Assistance required
Transferring (i.e. bed to chair or wheelchair to toilet) *

Does not require assistance Assistance required
Walking *

Does not require assistance Assistance required
Cooking *

Does not require assistance Assistance required
Housekeeping *

Does not require assistance Assistance required
Shopping *

Does not require assistance Assistance required
Laundry *

Does not require assistance Assistance required
Using the phone *

Does not require assistance Assistance required
Taking medication *

Does not require assistance Assistance required
Budgeting *

Does not require assistance Assistance required
Feeding Yourself *

Does not require assistance Assistance required
Sitting up *

Does not require assistance Assistance required
Standing *

Does not require assistance Assistance required
Lifting 3 lbs. *

Does not require assistance Assistance required
Reaching *

Does not require assistance Assistance required
Climb stairs with a railing *

Does not require assistance Assistance required
Climb stairs without a railing *

Does not require assistance Assistance required
Stepping up/down curbs *

Does not require assistance Assistance required
What devices do you use to move about?

Wheelchair Cane 4 point cane/Hemi-cane Crutches Walker 4 Wheel Walker Platform Walker
How far can you walk using any assistive device needed (cane, 4 point cane, crutches, walker, etc.) measured in feet or city blocks *
Distance you are able to walk is in feet or city blocks?

Feet City blocks
Do you need help from another person to walk? *

Yes No
If yes to the above question how much assistance do they provide? Please indicate as a percentage (0% for no assistance, 100% for completely dependent on another person to walk)?
%
Can you manage stairs? *

Yes No
Can you manage steps? *

Yes No
Can you manage curbs? *

Yes No
Which impairment limits your walking the most, if any?
Please share any other relevant information we may have missed regarding your abilities or disabilities:
What could you do before that you cannot do now?
What would you like to be able to do that you cannot do now?
What are the major goals you would like to achieve here at Challenge Center? *
Are you currently receiving PT, OT or ST at another facility? *

Yes No
If yes, which facility?
If yes, how often do you receive services?
times a week/month
Do you receive assistance from another person in your daily life? *

Yes No
If yes, how many hours per day?
If yes, how many days per week?
Who assists you?
CAREGIVER TRAINING

If you have a caregiver/friend/family member that assists you with daily activities, please have them fill this out, or fill it out with them
Does your caregiver feel they are at risk for a back injury because of the tasks you perform as a caregiver?

Yes No
Has your caregiver been trained in good body mechanics while performing your caregivning tasks (e.g. transfers, bed mobility, bathing, etc.)?

Yes No N/A
Would you like us to provide training regarding your role as a caregiver?

Yes No
What can we help you with regarding caring for and assisting your client or loved one?
Please provide any additional information you would like us to know, or any questions or concerns you may have:
Date

Month Day Year
Date
Signature

Clear
Have you received a Covid-19 vaccine?

Yes No
If so, have you received both shots (if needed)?

Yes No
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Contact Information

Medical History

Surgical History

Other Hospitalization(s)

Previous Rehabilitation

Medications

Symptoms

Pain

Physical Impairments

Activities of Daily Living

CAREGIVER TRAINING