S&H Pilot Intake and Assessment for Group Trainees

S&H Pilot Intake and Assessment for Group Trainees
THE BRAINING CENTER IS NOT A MEDICAL CLINIC. WE DO NOT CLAIM TO DIAGNOSE, TREAT, PREVENT OR CURE ANY MEDICAL CONDITIONS.
Name

First NameMiddle NameLast Name
Member ID #
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Emergency Phone

Area CodePhone Number
E-mail
Best Way to Contact
Do you wear glasses or contacts?
Do you wear hearing aids?
Do you have any physical or cognitive concerns? Please explain.
Qualification Questionnaire
1. Do you have any medical or cognitive issue that would make participating in a group fitness class unwise or dangerous?
If yes, explain.
5. Are you physically able to do light exercise independently for up to 50 minutes (stepping, tapping, marching, moving arms, clapping, hand/finger movements, and balancing)?
If no, explain.
6. Are you fully recovered from all surgeries you've had, and cleared by your doctor to do light exercise independently for up to 50 minutes?
If no, explain.
Walking Assessment
Member should walk along the straight line on the floor that is 8 feet in length, then turn around and walk back along the same line. It is unusual that someone will not be able to complete this task, however, if they cannot complete the task with ease, we must request a doctor's note before going any further in testing or training. Walking problems can be related to a variety of problems from dehydration to infection to neurological issues.
Member Completed Task

Training Ability Summation
Limitations Notes (Score 2)
Cannot Train Notes (Score 3)
Balance Assessment
Stand on one foot, while the other knee points towards the ground, with arms crossing your chest. I will time how long you can balance without putting your foot down, hopping, or otherwise losing the balance position for up to 1 minute. You will do it 2 times on each foot and your score will the be longest time on each foot. If person balances for at least 45 seconds, it is not necessary to give them additional trials.
Right Foot Trial 1
Seconds
Right Foot Trial 2
Seconds
LONGEST RIGHT FOOT
Seconds
Left Foot Trial 1
Seconds
Left Foot Trial 2
Seconds
LONGEST LEFT FOOT
Seconds

Condition Rating
Look at the following conditions and rate them according to how much each one impacts your daily life, where:

0= It does not impact my life at all, 5= It impacts my life somewhat, 10= It impacts me constantly
Memory Loss
Arthritis
Insomnia
Fatigue
Anxiety
Depression
Physical Exhaustion
Poor Dexterity
Breathing Difficulty
Lack of Motivation
Feeling Lonely/Isolated
Declining Driving Skills
Conditions Score

Grip Strength

in PSI, with 2" bulb and long tube
Right Hand Trial 1
Left Hand Trial 1
Right Hand Trial 2
Left Hand Trial 2
Right Hand Trial 3
Left Hand Trial 3
Right Hand Average
Left Hand Average
Pincer Strength

in PSI, with 2" bulb and long tube
Right Hand Trial 1
Left Hand Trial 1
Right Hand Trial 2
Left Hand Trial 2
Right Hand Trial 3
Left Hand Trial 3
Right Hand Average
Left Hand Average
CNS-VS

Member should now take CNS-VS. Result entered later
Total Test Time
Min:Sec

Neurocognitive Index

Rows	Score	Percentile Rating	Age/Ability Level
Neurocognitive Index
Composite Memory
Verbal Memory
Visual Memory
Psychomotor Speed
Reaction Time
Complex Attention
Cognitive Flexibility
Processing Speed
Executive Function
Simple Attention
Motor Speed

Visual Memory Test

Rows	Score	Percentile Rating	Age/Ability Level
Correct Hits Immediate
Correct Passes Immediate
Correct Hits Delay
Correct Passes Delay

Finger Tapping

Rows	Score	Percentile Rating	Age/Ability Level
Right Taps Avg.
Left Taps Avg.

Symbol Digit Coding

Rows	Score	Percentile Rating	Age/Ability Level
Correct Responses
Errors

Stroop Test

Rows	Score	Percentile Rating	Age/Ability Level
Simple Reaction Time
Complex Reaction Time Correct
Stroop Reaction Time Correct
Stroop Commission Errors

Shifting Attention

Rows	Score	Percentile Rating	Age/Ability Level
Correct Responses
Errors
Correct Reaction Time

Continuous Performance Test

Rows	Score	Percentile Rating	Age/Ability Level
Correct Responses
Omission Errors
Commission Errors
Choice Reaction Time Correct

Should be Empty:

S&H Pilot Intake and Assessment for Group Trainees

Qualification Questionnaire

Walking Assessment

Balance Assessment

Condition Rating

Grip Strength

Pincer Strength

CNS-VS