Stroke Rehab Class Health Questionnaire
Please complete this questionnaire before attending the stroke rehab classes. It gives me a heads up about anything I need to know about you.
If you have any questions at all, please contact me through my website at www.ReesFitness.co.uk/contact
Email address *
Your first name *
Your last name *
Approx date you had your stroke *
MM
/
DD
/
YYYY
Do you need help from anyone else to STAND and BALANCE upright? *
Required
Rate your confidence in WALKING (with aids such as sticks etc) without help from other people. *
Unable
Fully confident
Rate the movement available in your affected ARM. *
None
Full movement
Rate the movement available in your affected HAND. *
None
Full movement
Rate your ability to talk *
Unable
No problems
Rate your vision *
Unable to see
Can see fine
Rate your hearing *
Cannot hear
Can hear fine
Any other information you think I should know?
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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