PD Boxing & Beyond Initial Assessment
Record participant details, readiness, baseline and recheck movement measures, safety observations, follow-up needs, goals, and instructor notes.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant and Readiness
Participant name
First Name
Last Name
Email
example@example.com
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Staff member
First Name
Last Name
Time since last PD medication
Mobility aid used today
Participant-reported exercise precautions or restrictions
Healthcare provider exercise release is on file
Yes
Participant intake is complete
Yes
Participant reports no new issue today that would make exercise unsafe
Yes
30-Second Chair Stand
Baseline stands
Baseline modification
Recheck stands
Recheck date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Timed Up & Go (TUG)
Baseline TUG Time (seconds)
Baseline Aid Used
Recheck TUG Time (seconds)
Recheck Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Comfortable Walk and Simple Dual-Task Movement
Comfortable Walk Baseline Distance
Comfortable Walk Baseline Time
Comfortable Walk Recheck Distance
Comfortable Walk Recheck Time
Comfortable Walk Recheck Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Simple Dual-Task Movement Baseline Task
Simple Dual-Task Movement Baseline Result
Simple Dual-Task Movement Recheck Result
Simple Dual-Task Movement Recheck Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assistance, Safety, Follow-up, and Notes
Completed baseline without hands-on assistance
Yes
Used a mobility aid
Yes
Needed a chair or other stable support for part of the baseline
Yes
A modification was used
Yes
Baseline was stopped or deferred because of a safety concern
Yes
Modification / observation
Follow-up needed before or during class
Primary participant goal
Instructor notes
Submit
Should be Empty: