The Edmond J. Safra Parkinson's Wellness Program Assessment Form
Thank you for your interest in the Edmond J. Safra Parkinson's Wellness Program at the Marlene Meyerson JCC Manhattan. Medical clearance is required to participate in the program. Please complete the following form, taking into consideration our program offerings and your physical abilities. If you need assistance filling out the form, please call 646.505.4383.
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Your Name *
Mailing Address *
Phone Number
Email address *
Date of Birth *
How did you hear about our program?
Emergency Contact / Relationship *
Emergency Contact Phone Number *
Current Diagnosis and Date of Diagnosis *
Who is  your treating neurologist? *
Are you on medication? *
Do you have any other medical conditions? *
Do you currently have an exercise routine? *
If yes, what is your exercise routine and how many times per week?
Are you able to do the following activities for 30 minutes or more?
Are you able to climb a flight of stairs? *
Do you have trouble walking? *
Do you use an assistive walking device?

Do you have any trouble with balance? *
Do you have any trouble with balance while sitting? *
Do you have any trouble with balance while standing? *
Do you have dizziness while standing/sitting/walking? *
If yes, please explain
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