Dance with Parkinson's New Student Questionnaire
This questionnaire is designed to help us get to know you, and to provide the best possible experience for our participants.

Please note while this form is encouraged, this form and each individual question is completely optional.

Students who choose to participate may be contacted over time in order to measure progress and allow us to best serve your needs.

Sincerely,
Urbanity Dance

Name *
Your answer
Phone number *
Your answer
Email *
Your answer
Have you ever participated in a movement program or support group for PD before? If yes, please list the program(s).
Your answer
Do you participate in any other physical activities? If yes, please list/describe.
Your answer
Are you a part of any other groups that meet regularly? If yes, please list/describe (PD related or not).
Your answer
How long have you been diagnosed with Parkinson's? (weeks, months, or years)
Your answer
What are you looking forward to about this program?
Your answer
Do you anticipate any challenges with this program?
Your answer
Do you encounter any physical challenges? If so, describe.
Your answer
Do you encounter any social challenges? If so, what?
Your answer
What do you hope to gain from Dance with Parkinson's?
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