PARTICIPANT MEDICAL FORM

Participant's Name

Formal Diagnosis

Doctor's Name

Allergies

Medications

Hearing or Vision Impairments

Seizures (severity/frequency)

Cognitive or Behavioural Issues

Mobility - Ambulatory, Mobility Aids/Adaptive Equipment Used

Comfort in Mobility - Are you able to independently:
Transfer from a chair to standing
YesNo
Transfer from a chair to the floor
YesNo
Transfer from the floor to a chair
YesNo
Transfer from the floor to standing
YesNo

Is a support person needed to assist with personal care needs (ex: washroom)?

Other Relevant Information

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