Get Moving Health Questionnaire
Please complete this form to let us know about you, your health conditions and ability.
Email address *
First name *
Your answer
Last name *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Contact number *
What is your telephone number?
Your answer
Emergency contact name *
Who should we contact in case of emergency?
Your answer
Emergency contact number *
How do we contact them if needed?
Your answer
What is your primary health condition? *
What is the main reason you want to Get Moving?
Do you need help from anyone else to STAND and BALANCE upright? *
How independent are you when it comes to standing?
Rate your confidence in WALKING (with aids such as sticks etc) without help from other people. *
How independent are you when it comes to walking by yourself?
No confidence
Total confidence
Rate the strength/mobility in your arms. *
How much use do you have in your arms?
Very low
High
Rate the strength/mobility in your hands. *
How much use do you have in your hands?
Very low
High
Rate your ability to talk *
How well can you talk and communicate to the public?
Very low
High
Rate your vision *
How well can you see things in everyday life?
Very poor
Good
Rate your hearing *
How well can you hear things in everyday life?
Very low
High
Any other information you think we should know?
Is there anything else about you and your physical abilities we should know in advance?
Your answer
Disclaimer *
You acknowledge that you or your carer will take full responsibility for any help with personal care during the class.
Required
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