Medical Statement

  • Medical Statement

    Client Record (Confidential Information) 

  • Submitting this form does not guarantee enrollment in specialized services at DRIVEN NeuroRecovery Center. All submissions will be reviewed by the Director of Neuro Services to assess eligibility. DRIVEN and its representatives retain sole discretion in determining program participation and reserve the right to decline services.

  • Medical Information

    Incomplete Medical Statements will not be reviewed. All fields must be completed before your submission can enter the review process. If a field does not apply to you, enter “N/A.”
  • Neurological Disorder(s) / Other Conditions or Injuries (select all that apply)*
  • Date of Injury / Diagnosis*
     - -
  • Start Date of Initial Inpatient Treatment
     - -
  • End Date of Initial Inpatient Treatment
     - -
  • Did you attend a rehabilitation hospital that specializes in your injury?*
  • Start Date of Treatment at Specializing Hospital
     - -
  • End Date of Treatment at Specializing Hospital
     - -

  • Please answer "Yes" or "No" to the following. Indicate “Yes” for those that either currently apply to you or have applied to you in the past.

    Do you have:

  • Ability to breathe on your own?*
  • History of chest pain?*
  • History of heart disease or any other heart valve disorder?*
  • Any chronic illness or condition?*
  • High blood pressure?*
  • Low blood pressure?*
  • Difficulty with physical exercise?*
  • Osteoporosis?*
  • Osteopenia?*
  • History of fractures?*
  • Advice from a doctor not to exercise?*
  • Pregnancy (now or within the last 6 months)?*
  • Asthma?*
  • Any other disease of the lungs or breathing problems?*
  • Muscle, joint or bone disorder?*
  • Any previous injuries?*
  • Were you ever treated by a doctor for this?*
  • Diabetes?*
  • Thyroid Condition?*
  • Cigarette Smoking?*
  • High Cholesterol?*
  • Obesity?*
  • History of heart problems in your immediate family?*
  • Hernia, or any condition that may be aggravated by intense exercise?*
  • Muscle tone?*
  • Spasticity?*
  • Hardware (rods, cages, etc.)?*
  • Hypersensitivity?*
  • Orthostatic hypotension (sudden drop in blood pressure when standing from a sitting or lying position)?*
  • Heterotopic Ossification?*
  • Contracture?*
  • Cognitive impairments?*
  • Thermoregulation issues?*
  • (Current) Pressure Sores?*
  • 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?*
  • Has your physician approved your participation in an exercise program?*
  • Are you accustomed to vigorous exercise?*
  • Is there any reason not mentioned here why you should not follow a regular exercise program?*

  • Please answer the following questions completely and thoroughly. 

  • Describe your physical abilities including controlled/uncontrolled movements, tone and/or spasms or joint issues. Be as specific as possible.

  • Are you able to sit independently?*
  • Are you able to stand independently?*
  • Are you able to perform a sit-up independently?*
  • Are you able to perform a seated trunk extension independently?*
  • Are you able to take steps with assistance?*
  • Are you able to take steps independently?*
  • Have you had a recent bone density assessment?*

  • If yes, please provide DRIVEN NeuroRecovery Center with a copy of the report including the doctor’s interpretation.

    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.

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