Internet Addiction Recovery Program APPLICATION ... - HEAL

PHYSICAL EXAMINATION (Continued)
Internet Addiction Recovery Program
The FOLLOWING CONDITIONS ARE CONTRAINDICATED FOR PARTICIPATION IN THE reSTART INTERNET ADDICTION RECOVERY PROGRAM. Please
indicate if the following conditions exist:
Hepatitis A, B or C (if contagious)
Chicken Pox, Measles, Mumps, Rubella or (other contagious
agent which would interfere with a group milieu)
Schizophrenia or mental illness w/psychotic features
Severe Cognitive Impairments (e.g., Traumatic Brain Injury, IQ <
90)
Last date of Tetanus Shot (within past 10 years) ____________________
Assessment:
Full participation
Limited participation (describe limitations, restrictions):
________________ ____
_______
Participation contraindicated (list reasons):
_________________
Recommendations (equipment, taping, rehabilitation, etc.):
_________________
Physician’s Summary
__________________
_____
________________ ________
PHYSICIAN’S SIGNATURE REQUIRED
Physician Name: __________________________________________________________________________________
Physician Signature: ________________________________________________ Date of exam: ___________________
Address: _________________________________________________________________________________________
Phone Number: _________________________________ Email Address: _____________________________________
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reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189
restart@netaddictionrecovery.com | www.netaddictionrecovery.com