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The Perfect Step Scheduling - Add TPS Application

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Clients Trainers Appointments Services Evaluation Forms Emotional Contentment Forms Client Quality of Life and Secondary Complications Forms Muscle Testing Forms Functional Movement Forms Return Client Questionnaire SCI Forms P4P Classes P4P Client Registration Application P4P Class Sign-Ups TPS Applications Client Feedback Forms Internship Feedback Form's PTH Podcast Feedback Forms Pedaling for Parkinson's Program Days Time Slots Client Interest Forms Release of Liability Forms

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The Perfect Step Application

Please allow yourself 30 minutes to fill out the application below. Once you begin, your application cannot be saved.

Please note that upon completing the application you will be contacted by our Administrative Assistant here at TPS. She will make you aware of some of the necessary next steps in the process to eventually schedule your initial evaluation. This will include: an updated bone density scan, and in addition to this you will then need to take your bone density scan to your primary care physician to write a release letter to us stating that you are in proper health to participate in an exercise-based therapy program. After those things are completed, among other things, you then will be eligible to schedule your initial evaluation date.

Client Contact Information

This information should be directly related to the individual who will be attending The Perfect Step. If you are completing this application on behalf of someone else, you may enter your contact information later.

First Name *

Last Name *

Address *

Cell Phone *

ext.

Home Phone

ext.

Email *

Primary Language

How did you hear about us?

Social media
Word-of-mouth
Referral from a friend
Referral from Dr.
Internet search
Flyer or ad
Other
None of the above

Client Demographics

Date of Birth *

Age *

Height (Ft) *

Height (In) *

Weight in pounds *

Gender *

Male
Female
Other
None of the above

Client Injury or Diagnosis

Date of Injury or Diagnosis *

Type of Injury/Diagnosis *

If Type of Injury/Diagnosis is Other then please put here

Type of Injury/Diagnosis - Level of injury if spinal cord injury

ASIA Score - this is self reported data that you would gather from your doctor who assessed you

Complete/Incomplete

If injured, how were you injured? Please be specific. (Example: auto accident, sports related injury, violence, etc.)

All of our clients are very unique. Please take a moment to tell us a little about your injury/diagnosis. For example, knowing the exact levels of injury for a spinal cord injury patient would help us understand how our program can help. Also, if you have an additional diagnosis beyond the primary listed above, please list those as well. *

Insurance Information

Name of Insurance Company - Please input even if you are not going to use your insurance (for research purposes) *

Insurance Policy Plan/Type/Description of plan - Please input even if you are not going to use your insurance (for research purposes) *

Phone Number

ext.

Treatment History

What hospital were you treated at? *

Treating Physician *

Date of Last Examination

Have you ever participated in an intense exercise-based program similar to The Perfect Step? *

Yes
No
None of the above

Program participated in? *

In order to create the best experience possible. Please take a moment to tell us a little about yourself. Information could be specific to your injury/diagnosis or could just give us a little more insight into who you are. Why? Because we care!

Attach a File (Doctors note, bone scan)

Physical Ability

Please provide as much detail about your current physical abilities. This section is one of the most important areas for determining the correct program for our clients and how The Perfect Step can potentially help.

Please describe your upper extremity ability. *

Please describe your core stability. *

Please describe your lower extremity ability. *

Please describe any physical problems or special considerations we should be aware of. *

Does the client wear a neck brace? *

Yes
No
None of the above

Is the client confined to a trach or ventilator? *

Yes
No
None of the above

Does the client have a previous/current history of seizures? (If yes, please briefly explain) *

Cognitive Ability

What is the clients ability to speak and communicate? *

What is the client's ability to understand direction? *

Rehabilitation

Describe your previous rehabilitation experience. *

Date of last rehabilitation

Have you had a recent bone density scan? *

Yes
No
None of the above

NOTE: It is required that ALL CLIENTS over 6 months post injury must obtain a bone density assessment and present a copy of the bone density report with the doctor's interpretation to The Perfect Step. We do not interpret bone density reports. Clients must update bone density assessment annually or as requested by The Perfect Step. Please discuss this policy with our team for more information as each client case is unique.

Medications

List all medications you are currently taking.

List
1. Medication
2. Dosage mg/day, and
3. Purpose for each medication

Medical History

History of heart disease or any other heart/valve disorder *

Yes
No
None of the above

History of Chest Pain *

Yes
No
None of the above

High Blood Pressure *

Yes
No
None of the above

Low Blood Pressure *

Yes
No
None of the above

Difficulty with Exercise *

Yes
No
None of the above

Osteoporosis *

Yes
No
None of the above

Osteopenia *

Yes
No
None of the above

History of Pathological Fracture *

Yes
No
None of the above

Are you currently pregnant *

Yes
No
None of the above

Asthma *

Yes
No
None of the above

Any other lung disease *

Yes
No
None of the above

Muscle, Joint or Back Disorder *

Yes
No
None of the above

Diabetes *

Yes
No
None of the above

Thyroid Condition *

Yes
No
None of the above

Cigarette Smoking *

Yes
No
None of the above

High Cholesterol *

Yes
No
None of the above

Hernia *

Yes
No
None of the above

Do you have a stint? *

Yes
No
None of the above

Do you currently have a pacemaker? *

Yes
No
None of the above

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 in this section? *

Yes
No
None of the above

Do you have a "G Tube"? *

Yes
No
None of the above

List any recent surgery (Last 12 months)

Do you currently have a pressure sore? *

Yes
No
None of the above

Physician Approval

NOTE: Physician approval may be required prior to your first session at The Perfect Step

Has your physician approved your participation in an intense exercise program? *

Yes
No
None of the above

Are you accustomed to vigorous exercise? *

Yes
No
None of the above

Is there any reason not mentioned here why you should not follow a regular exercise program? *

Yes
No
None of the above

Please make any other comments you feel are pertinent to your recovery program.

Employment

Do you pay into/have access to an HSA (Health Savings Account)/FSA (Flexible Spending Account) interest-bearing account? *

Yes
No
I don't know
None of the above

Program Options

The Perfect Step offers various programs that range from Facility Training sessions to Home Recovery Programs. All of the programs are tailored to meet each client's recovery needs. A brief overview of these programs are below, but please review our website for more information or contact your local The Perfect Step facility. NOTE: Program costs will vary per location. Please contact your local The Perfect Step facility for specific program costs and to set up a tour.

Local Client Program: This program is for clients who will attend on a regular basis (daily/weekly/monthly)

Visiting Client Program: This program is designed for clients who do not live near one of our locations. Visiting programs are a minimum of one week.

Train Your Trainer Program: Similar to the Visiting Client Program but allows for a friend or family member to receive training in our method.

Home Recovery Program: The Perfect Step provides clients who may never be able to attend a location with access to online recovery materials. Skype training sessions and customized prescriptions.

Program selection on this application simply gives us a better understanding of how we might help you. Feel free to contact your local facility for more information on choosing the program that is best suited for you.

Please select a program

Local Client Program
Visiting Client Program
Train Your Trainer Program
Home Recovery Program
Not Sure
None of the above

Request Start Date *

Billing Information

Please indicate how you anticipate paying for your program. This does not legally bind you to any form of payment or to our program. This is simply to help our team process your application and prepare your program.

Preferred Payment Method *

Check/Cash
Credit Card
Payment will be made by a third party organization
None of the above

Statement of Accuracy

I have completed this application to the best of my knowledge in order to make known any diagnosed medical characteristics that may increase the risk of health problems, signs or symptoms indicative of health problems, and lifestyle behaviors related to positive or negative health, which will enable The Perfect Step to determine if a medical clearance is needed before beginning an exercise program.

I understand that if necessary The Perfect Step reserves the right to request medical clearance which may involve a bone scan and physician's evaluation and approval before beginning any exercise program, and have the right to deny my participation in the program if requests are not fulfilled and/or if I do not qualify as determined in the sole discretion of The Perfect Step.

PLEASE NOTE: Your completed application will be electronically transmitted, and upon arrival at The Perfect Step facility, further signatures may be obtained during your check-in prior to your initial evaluation.

Date of Acknowledgement *

Name of Parent/Guarding (if necessary)

First *

Last *

I have read, understand, and agree to the terms and conditions of this agreement. *

SUBMIT

SUBMIT

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If you want to create three separate Acme records (Acme-New York, Acme-Dallas and Acme-Portland) click the Conform link at the top of the column.
If the dissimilar entries are mistakes (say Acme only has one office in New York and the other locations are data-entry errors) go back into your table and correct the inconsistencies�in this case, changing all locations to New York. Then try the conversion again.

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