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Virtual Intake Form

We are excited to meet you soon in a Power Over Dementia exercise class.  Please complete the intake form below, so that we can get to know you.  We will also use the information you provide to aid in class assignments.  At POD Fitness we work as partners, so you will see sections for both the primary athlete and their partner.  

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Exercise is good for the brain, but so is socialization.  We hope POD Fitness will help connect you with others who understand, as they are walking a similar journey.

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We will not share your information outside of our organization, and we will not share your information.  

Primary Athlete Information

Person living with mild cognitive impairment (MCI), dementia, or undiagnosed brain change.

Does the primary athlete have a Power of Attorney?
Has a physician cleared the primary athlete to exercise?
Date of birth
Month
Day
Year
Have you been hospitalized in the last 12 months?
No
Yes
Have you fallen in the last 3 months?
No
Yes
Any episodes of dizziness or lightheadedness?
No
Yes
Any episodes of chest pain or heart palpitations?
No
Yes
Any aches/pains that might make exercise challenging?
No
Yes
Any shortness of breath with daily activities?
No
Yes
Have you been diagnosed with any of the following?
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Care Partner Health Information

A Care Partner is anyone willing to support the person living with MCI or Dementia during POD Fitness classes. This could be a spouse, family member, friend, or paid professional caregiver. And since your health is also valuable, we encourage you to exercise with us.

Birthday
Month
Day
Year
Has a physician cleared you to exercise?
No
Yes
Have you been hospitalized in the last year?
No
Yes
Have you fallen in the last 3 months?
No
Yes
Any episodes of dizziness or lightheadedness?
No
Yes
Any episodes of chest pain or heart palpitations?
Option 1
Option 2
Are you experiencing any aches/pains that might make exercise challenging?
No
Yes
Any shortness of breath with daily activities?
No
Yes
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