Silver Sneakers
Falls Risk Factor Checklist Screening
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Checklist Screening
*
Rows
Yes
No
Have you had any trips, slips, falls (or near falls) in past year?
Can’t get out of a chair without using your hands?
Do you feel unsteady when standing or walking?
Do you Limit or avoid activities because you’re afraid of losing balance or falling?
Would you like a home strength self assessment form emailed to you?
Would you like us to add you to our monthly Silver Sneakers newsletter that gives you information on senior specific fitness information, tips and tricks? We confirm that your details will be kept private and confidential. You can unsubscribe from our email at anytime.)
Submit
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