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SAN JOSE CITY COLLEGE
Disabilities Support Program & Services
2100 Moorpark Avenue, San Jose, CA 95128 (408) 288-3746 Fax: (408) 971-8201
Adapted Physical Education Health Verification
MEDICAL REFERRAL FORM
Name: SS#: Date:
Address: City: Zip Code:
Date
of Birth: Age: ___________________________
Signature of Student for Release of Information
Your patient desires to enroll in an Adapted Physical Education class at San Jose City College. These classes are highly
specialized and individualized in order to meet the needs and interest of your patient. All classes are taught by a Certified
Adapted Physical Educator. We need your assistance in verifying your patient's disability and functional limitations, in order
to plan a comprehensive program. Please complete the following and return to the Disabilities Support Program & Services at
the address above. In order for your patient to enter our class we must have this form on file.
For More Information contact:
Tait Rafat, Coordinator of Adapted Physical Education, San Jose City College, 408-288-3732
THANK YOU.
A. Diagnosis and /or Disability: __________________________________________________________________
B. Functional Limitations: _______________________________________________________________________
C. Brief Prognosis and Limiting Effects: ___________________________________________________________
Please check which activities would be most beneficial for this student.
GROUP ACTIVITIES PROGRESSIVE STRENGTHENING EXERCISE
Adapted Sports & Games Circuit Conditioning
General Conditioning Dumbbell Exercises
NON-WEIGHT BEARING ACTIVITIES MILD CARDIOVASCULAR CONDITIONING
Range-of-Motion Stationary Bicycle Rowing Machine
Active Stretching Swimming
Treadmill
WEIGHT BEARING ACTIVITIES
Ambulation
Standing Frame
CONTRAINDICATIONS:
Partial Weight Bearing __________________________________________________
Non-Weight Bearing __________________________________________________
Health Care Professional Health Care Professional's Signature Telephone Number
Facility Address City Zip
DSP&S - APE_med.frm
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