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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.

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

Or fill out  form below:

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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.

 

Do you have: 

Ability to breathe on your own
History of chest pain:
Heart disease/disorder
Chronic illness/disorder
High blood pressure:
Low blood pressure:
Difficulty with exercise:
Osteoporosis:
Osteopenia:
Pathological fracture:
Doctor advice not to exercise:
Surgery other that SCI (12mo):
Pregnancy (now or with in 3mo):
Breathing/lung problems:
Asthma:
Other disease of the lungs:
Muscle, joint, back disorder:
Diabetes:
Thyroid condition:
High cholesterol:
Smoke cigarettes:
Obesity:
Tone:
Spasticity:
Hardware (rods, cages, etc.):
Hypersensitivity:
Low blood pressure:
Heterotopic Ossification:
Contracture:
Cognitive impairments:
Thermoregulation Issues:
Pressure sore(s):

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:
If yes, please attach report:

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!

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