Language
English (US)
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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