Balance Screening Event Signup
Thank you for your interest in our Balance Screening! This complimentary screening is designed to identify factors that may contribute to falls, balance difficulties, or reduced confidence with movement. Please complete the form below before your appointment. Your responses help our physical therapists provide a safe and individualized screening.
Full Name
*
First Name
Last Name
Email Address
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you been seen at Activate Physical Therapy before?
Yes
No
What prompted you to sign up for a balance screen?
I have experienced a fall
I have had a near-fall or feel unsteady
I feel less confident walking
I have difficulty with stairs
I have difficulty getting up from a chair
I want to proactively assess my fall risk
My healthcare provider recommended a balance screening
Family/friend encouraged me to participate
Other
Have you fallen in the past 12 months?
No
Yes - once
Yes - 2 or more times
If Yes, when was your most recent fall?
Have you been diagnosed with or are you currently being treated for any of the following?
Parkinson's disease
Stroke/TIA
Multiple Sclerosis
Brain Injury/Concussion
Neuropathy
Vestibular disorder/vertigo
Arthritis
Osteoporosis
Low blood pressure
Heart condition
Diabetes
Vision Impairment
Other neurological condition
None of the above
Do you use any of the following?
Cane
Walker
Four Wheeled Walker/Rollator
Wheelchair
None
Do you experience any of the following?
Dizziness
Vertigo/spinning
Lightheadedness when standing
Loss of balance
Leg weakness
Numbness/tingling in your feet or legs
Vision changes that affect walking
None of the above
Are you comfortable participating in simple standing and walking balance activities?
Yes
No
Do you require assistance from another person to walk safely?
Yes
No
Are you currently experiencing any pain or injury that could affect your ability to stand, walk or participate in a balance screening? If Yes, please explain.
Do you currently take any medications that may affect your balance, blood pressure, alertness or coordination?
No
Yes
I'm not sure
Have you had any recent changes to your medications?
No
Yes
I'm not sure
Do you use glasses or contacts?
No
Yes
Do you use hearing aids?
No
Yes
Do you live alone?
No
Yes
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Appointment
*
Consent
I understanding that this is a complimentary balance screening and not a full physical therapy evaluation. I understand that I may stop participating at any time.
Signature
Submit Registration
Submit Registration
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