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Hi there, please fill out and submit this form & we can better assist you or your loved one. Got Questions? Reach out to us : (208)205-9559 or Idaho@Kit-Therapy.com *We're here to help!
18
Questions
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1
Name
First Name
Last Name
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2
Email
example@example.com
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3
Phone Number
Area Code
Phone Number
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4
Date
-
Date
Year
Month
Day
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5
Whose information will you be providing?
Please Select
My Own Information.
A friend of family members information.
A Clients information.
Please Select
Please Select
My Own Information.
A friend of family members information.
A Clients information.
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6
Have you fallen in the past year?
YES
NO
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7
I use or have been advised to use a cane or walker to get around safely.
YES
NO
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8
Sometimes I feel unsteady when I am walking.
YES
NO
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9
I steady myself by holding onto furniture when walking at home
YES
NO
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10
I am worried about falling.
YES
NO
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11
I need to push with my hands to stand up from a chair.
YES
NO
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12
I have some trouble stepping up onto a curb.
YES
NO
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13
I often have to rush to the toilet.
YES
NO
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14
I have lost some feeling in my feet.
YES
NO
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15
I have had physical or occupational therapy this year to address my balance.
YES
NO
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16
Do you have Any Pain, Injury, or Weakness?
YES
NO
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17
If you answered yes above, please tell us more about your pain, injury, or weakness.
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18
If I am a candidate for a Fall Safety Balance Assessment & I choose to use my insurance, this is my medical insurance carrier(s).
Medicare
Private Insurance Plan
Medicare with a Secondary Plan
VA
Medicare Advantage Plan
Other
Other
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