Therapeutic Recreation Participant Health and Wellness Intake Form with Health Screening Δ
Therapeutic Recreation Participant Health and Wellness Intake Form with Health Screening Disability, Diagnosis and Health Background
What disability, diagnosis, condition, or health concern would you like us to know about?
Secondary disability or conditions
How does your condition impact participation in recreation or physical activity?
Are there specific symptoms, limitations, or warning signs staff should recognize?
Assistive Devices and Support Needs
Do you use any adaptive equipment or assistive devices? (wheelchair, walker, communication device, braces, hearing or vision supports, etc.)
Do you require assistance with transfers, positioning, mobility, or personal care?
Do you need a support person, caregiver, aide, or interpreter during programs?
Are you comfortable with staff taking a hands-on approach for safety, positioning, or instruction?
Health Screening Please answer the following questions. If you answer yes to any item, additional health information may be needed before participation.
Has a healthcare provider ever told you that you have a heart condition or that you should only do physical activity recommended by a healthcare provider?
Details: Has a healthcare provider ever told you that you have a heart condition or that you should only do physical activity recommended by a healthcare provider?
Do you feel pain in your chest during physical activity?
Details: Do you feel pain in your chest during physical activity?
In the past month, have you had chest pain when not doing physical activity?
Details: In the past month, have you had chest pain when not doing physical activity?
Do you lose consciousness, feel dizzy, or lose balance because of a health condition?
Details: Do you lose consciousness, feel dizzy, or lose balance because of a health condition?
Have you ever been diagnosed with a neurological condition (such as seizures, stroke, traumatic brain injury, or other condition) that may affect participation?
Details: Have you ever been diagnosed with a neurological condition (such as seizures, stroke, traumatic brain injury, or other condition) that may affect participation?
Do you have a bone, joint, muscle, or connective tissue problem that could be made worse by activity?
Details: Do you have a bone, joint, muscle, or connective tissue problem that could be made worse by activity?
Do you take medications that affect your ability to exercise safely (such as seizure medication, heart medication, or medications affecting alertness)?
Details: Do you take medications that affect your ability to exercise safely (such as seizure medication, heart medication, or medications affecting alertness)?
Do you have any other medical condition or concern that may affect safe participation?
Details: Do you have any other medical condition or concern that may affect safe participation?
Seizure and Medical Safety Information
Do you have seizures or a seizure disorder?
What type of seizures, triggers, warning signs, or response procedures should staff know?
Emergency action plan or medical instructions
Sensory, Communication and Learning Preferences
Do you have sensory needs? (noise, lighting, touch, crowded spaces, textures, etc.)
Do you prefer low-sensory environments or sensory input activities?
What teaching methods work best? (visuals, demonstrations, repetition, step-by-step instructions, verbal cues, etc.)
What communication supports help you participate successfully?
Goals, Motivation and Recreation Preferences
What are your goals for participating?
What activities do you enjoy or want to try?
What motivates you during challenging activities?
How can staff best support you through frustration, anxiety, or challenges?
Behavioral, Emotional and Mental Health Considerations
Are there emotional, behavioral, or mental health considerations staff should understand?
Are there triggers, calming strategies, or coping supports that help you?
What helps you feel safe and comfortable in a recreation environment?
Additional Information and Consent
Is there anything else you would like the Therapeutic Recreation Department to know?
Submit
