Neurological Disorder SCI TBI Stroke CP Hospitalized recently? (12 mo) Yes No
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.
Do you have:
Ability to breathe on your own
Difficulty with exercise:
Doctor advice not to exercise:
Surgery other that SCI (12mo):
Pregnancy (now or with in 3mo):
Other disease of the lungs:
Muscle, joint, back disorder:
Hardware (rods, cages, etc.):
Are you aware of any disease or disorder that would complicate your participation in an exercise program, other than the medical conditions you have checked above?
Please explain your regular exercise routine. Is it doctor approved? Is there any reason not mentioned that you should not follow a regular exercise program?
Please answer the following questions completely and thoroughly:
List ALL assistive devices you use in everyday life, even if only for short periods (ie:, walker, type of wheelchair, AFO, Abdominal Binder, etc.):
Describe your physical abilities including controlled/uncontrolled movements, tone and/or spasms or joint issues. Be as specific as possible:
Able to sit independently:
Able to stand independently:
Able to sit-up independently:
Trunk extension independently?
Take steps independently:
Take steps with assistance:
NOTE: For safety reasons, clients with no bone density assessment or medical report of bone density assessment will be assumed to have osteoporosis. This may place limitations on the exercises used for your exercise program and prescription. Submit