Ability Fitness Clinic Online Registration

Client Name:

Nickname:

Date of Birth

Gender

Parent / Client Address

City

State:

Zip Code:

Email Address:

Phone:

Alternate Phone:

Emergency Contact Name:

Relationship to Client:

Phone:

Alternate Phone:

Diagnosis/ Current Level of Function

Does client have seizures?

If yes, please indicate what type and how often:

Medications/ taken for/ side effects:

Current language skills or expressive skills:

Current interests and hobbies:

Dislikes and Special Concerns:

Describe Fitness Goals

Behavioral Characteristics exhibited include: (Select all that apply)

If others, please explain:

If others, please describe:

If others, please describe:

Triggers of unfavorable behavior (select all that apply)

If others, please desribe:

Helpful Instructional Strategies (Select all that apply)

If Others, plese describe

Suggestions for Successful Participation

If Others, please describe:

Motor behavior currently demonstrated by individual

If others, please describe:

Length of activity time tolerated by individual

Please provide any other pertinent information regarding the clients motor abilities

Diagnosis/ Current Level of Function

Does client have seizures?

Other Problems:

Please list other conditions not already mentioned:

Please list all recent surgeries:

Please list all known allergies:

If you're male, are you 45 years old or older?

If you're female, are you 55 years or older?

Has your father or brother experienced a heart attack, heart surgery, or sudden cardiac death before age 55?

Has your mother or sister experienced a heart attack, heart surgery, or sudden cardiac death before age 65?

Has your doctor told you that you have high blood pressure?

What is your Blood Pressure?

Are you on blood pressure lowering medication?

Has your doctor told you that you have high cholesterol?

Do you know your cholesterol levels?

Total:

HDL:

LDL:

Are you on cholesterol lowering medication

Do you have prediabetes or diabetes?

Do you know your fasting blood sugar level?

What is your fasting blood sugar number?

Are you physically inactive (you get less than 30 minutes of physical activity less than 3 days a week)

Do you currently smoke or are you consistently exposed to environmental smoke?

How many cigarettes do you smoke per day?

Have you quit smoking in the last 6 months?

Height (inches)

Weight (lbs)

What is your occupational activity level?

Do you currently engage in any vigorous physical activity on a regular basis?

If so, what type?

How many days per week?

How much time per session?

Do you engage in any recreational or leisure-time physical activity on a regular basis?

If so, what activities?

On average, how many times per week?

On average, how long is each recreation and leisure activity session?

Please indicate the reasons why you want to start an exercise program (check all that apply).

If other, please list:

Client's Name

Anticipated AFC Missed Dates

Client's T-Shirt Size

Explanation for Participation & Evaluation
Your son/daughter/guardian will be asked to perform certain procedures and tasks which will aid in the evaluation of current fitness levels. This may include all or part of the following: weight, percent body fat, resting blood pressure, and measurements for flexibility and muscular strength, and endurance measures. In some cases, your son/daughter/guardian will be asked to begin a certain work level and progress until he/she can no longer perform the test. Although he/she will be encouraged to perform to their best ability, we do not wish for anyone to perform these tests at a level which is abnormally uncomfortable. At any time, that all or any portion of the procedures described above may be terminated without penalty.

Risks and Discomforts
There exists the possibility of certain changes to occur during the tests and activities. They include abnormal blood pressure, fainting, disorders of heart beat, and in very rare instances, injury. Every effort will be made to minimize these by the preliminary screening and by observations during testing and activities. Emergency equipment and trained personnel are available to deal with these situations should they happen.

Benefits to be expected from participation
Many benefits may occur from your son/daughter/guardian's participation including: increased cardio respiratory capacity, improved skill level, opportunities for social interaction and enhancement, and incidental improvements from participation. Additionally, the clinic also provides parents/guardians to observe the activities and benefit from this observation.

Confidentiality
The information which is obtained during the laboratory evaluation of the Ability Fitness Clinic will be treated as privileged and confidential and will not be released without your consent. The information obtained, however, may be used for statistical or scientific purpose with your right to privacy retained. In addition, we asked that we be allowed to videotape and photograph your son/daughter/guardian for instructional purposes. Your consent will be asked for any other use of the videotapes and/or pictures (e.g., University programs).

Freedom of Consent
If you have any doubts or questions, please do not hesitate to ask. Permission for your son/daughter/guardian's participation is voluntary. You are free to deny consent if you so desire or withdraw at any time.

I have read this form and understand the test procedures to be performed.

I consent to participate in the program.

IUPUI Adapted Movement Programs (AMP) have many exciting programs we would like to be able to share with the community via social media (Facebook, Instagram, Twitter). In order to do so, there will be times when we may need to take pictures of your child at during participation in clinic.

If you do not wish for your child to be photographed or video-taped during these clinics for social media purposes of the AMP program promotion, please select NO so we can retain this for our records.