Health Form – TA Online

Therapeutic Adventures, Inc.

CONFIDENTIALITY/PRIVACY NOTICE – This document contains information that is confidential and/or legally privileged. The contents provided are intended to provide registered Therapeutic Adventures – instructors/adaptive guides with necessary information so that programs can be safely administered.

Name

First

Middle

Last

DIAGNOSIS

Date of Injury or Onset

(MM/DD/YYYY)

Primary Diagnosis

Secondary Diagnosis

Please Describe (if Other):

6 FOR Please

OTHER HEALTH / MEDICAL NEEDS THAT MAY REQUIRE SPECIAL ATTENTION

Please Describe (if Other):

LIMITATIONS FOR ACTIVITY

Has any physician advised you to limit your activity?

Yes
No

If YES, please describe:

Please indicate the contraindications for activity that will require special attention?

Do you have a Hx of any back, shoulder, knee, or other joint problems?

Yes
No

If YES, please describe:

Any surgery in the last 6 months?

Yes
No

If YES, please describe:

PRESCRIPTION MEDICATIONS

Currently taking any medications?

Yes
No

Please list any medication that will be taken during the program / event:

Name of Medication / Purpose / Amount / Frequency / Time

ASSISTIVE DEVICES / MOBILITY EQUIPMENT USED

Please Describe (if Other):

FUNCTIONAL MOBILITY

Please check (✔️) any that apply and describe below

Requires assistance for some walking: ascending/descending moderate inclines, uneven or rough terrain‎
Requires assistance for some wheelchair mobility: ascending/descending moderate inclines, uneven or rough terrain, transfers‎
Other (specify)

Please Describe (if Other):

Name of Participant

First

Last

Date

MM/DD/YYYY