Activity Based Therapy | Southern California | Reneu Health, Inc.

San Diego: 619.263.0239

Los Angeles & Orange County: 949.245.6239

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Aging is Certain, Decline is Not.

CLIENT APPLICATION

If you would like to fill out an application to become a Reneu Health client, click on our online application or download and print the application in pdf format below. Once your application is reviewed, we will contact you.

NOTE: Completion of this application does not guarantee your participation in our program.

Or fill out form below:

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

Yes

No

History of chest pain:

Yes

No

Heart disease/disorder

Yes

No

Chronic illness/disorder

Yes

Yes

High blood pressure:

Yes

No

Low blood pressure:

Yes

No

Difficulty with exercise:

Yes

No

Osteoporosis:

Yes

No

Osteopenia:

Yes

No

Pathological fracture:

Yes

No

Doctor advice not to exercise:

Yes

No

Surgery other that SCI (12mo):

Yes

No

Pregnancy (now or with in 3mo):

Yes

No

Breathing/lung problems:

Yes

No

Asthma:

Yes

No

Other disease of the lungs:

Yes

No

Muscle, joint, back disorder:

Yes

No

Diabetes:

Yes

No

Thyroid condition:

Yes

No

High cholesterol:

Yes

No

Smoke cigarettes:

Yes

No

Obesity:

Yes

No

Tone:

Yes

No

Spasticity:

Yes

No

Hardware (rods, cages, etc.):

Yes

No

Hypersensitivity:

Yes

No

Low blood pressure:

Yes

No

Heterotopic Ossification:

Yes

No

Contracture:

Yes

No

Cognitive impairments:

Yes

No

Thermoregulation Issues:

Yes

No

Pressure sore(s):

Yes

No

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:

Yes

No

Able to stand independently:

Yes

No

Able to sit-up independently:

Yes

No

Trunk extension independently?

Yes

No

Take steps independently:

Yes

No

Take steps with assistance:

Yes

No

If yes, please attach report:

Max File Size 15MB

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.

Thanks for submitting!

San Diego County, CA

PO Box 12817/San Diego/Ca 92112

o: 619.263.0239

f: 619.858.2210

e: info@reneu-health.com

Orange County, CA

Orange County, CA

o: 619.263.0239

c: 949.245.6239

e: info@reneu-health.com

Los Angeles County, CA

Los Angeles County, CA

o: 619.263.0239

c: 949.245.6239

e: info@reneu-health.com