PARTICIPANT INTAKE FORM

GENERAL INFORMATION

// (mm/dd/yyyy)

ADDRESS INFORMATION

EMERGENCY CONTACT INFORMATION

Spouse
Partner
Son
Daughter
Mother
Father
Caregiver
Other

PARENT/GUARDIAN INFORMATION

Spouse
Partner
Son
Daughter
Mother
Father
Caregiver
Other

PARTICIPANT INFORMATION

MEDICAL INFORMATION

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

PHYSICAL INFORMATION

Yes
No
Yes
No
Yes
No
Yes
No
N/A
Yes
No
N/A
Yes
No
Yes
No
None
Power Wheelchair
Manual Wheelchair
Cane
Walker
Crutches
None
Poor
Fair
Average
Good
Excellent
None
Braces
Prosthetic(s)
Other
None
Poor
Fair
Average
Good
Excellent
No Assistance
Partial
Total
N/A
None
Poor
Fair
Average
Good
Excellent
N/A
Yes
No
N/A
Yes
No
Yes
No

BEHAVIORAL INFORMATION

Yes
No
Yes
No
Poor (0-1 minute)
Fair (1-5 minutes)
Average (5 minutes)
Good (more than 5 minutes)
Visual-learns by seeing
Auditory-learns by hearing
Kinesthetic-learns by doing

SENSORY INFORMATION

Totally blind
Partially sighted
Legally blind
N/A
Total hearing loss
Partial hearing loss
N/A
None
Conclear implant
ASL
English
Other

PROGRAM SPECIFIC INFORMATION

Female
Male
N/A
Ski
Snowboard

LEISURE INFORMATION

Yes
No
Yes
No
Yes
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