A Matter of Balance-Virtual (AMOB-V)
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1)
Which Workshop would you like to register for?
Tuesdays 5/11/2021 7/6/2021 10:00am-12:00pm
Fridays 5/21/2021 7/16/2021 1:00pm-3:00pm
Wednesdays 6/2/2021 7/28/2021 2:00pm-4:00pm
Thursdays 6/17/2021 8/19/2021 9:00am-11:00am
Mondays 7/12/2021 9/13/2021 2:00pm-4:00pm
Tuesdays 7/20/2021 9/14/2021 10:00am-12:00pm
Fridays 8/13/2021 10/8/2021 1:00pm-3:00pm
Wednesdays 9/15/2021 11/10/2021 2:00pm-4:00pm
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2)
First Name:
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3)
Last Name:
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4)
Gender
Male
Female
Prefer not to answer
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5)
Date of Birth
Month
Day
Year
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6)
Address
Street:
City:
State:
Zip code:
County:
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7)
Phone Number including area code (555-555-5555)
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8)
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Ethnicity Not Reported
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9)
Race
White - Non Hispanic
White - Hispanic
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
Persons Reporting Some Other Race
Race Not Reported
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10)
Marital Status
Married
Widowed
Divorced
Separated
Never Married
Not Reported
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11)
Do you live alone?
Yes
No
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12)
Do you consider yourself low income?
Yes
No
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13)
Monthly Income
--Select--
$12760 or below
$12761 to $23791
$23792 to $36156
$36157 to $48521
$48522 and above
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14)
Emergency Contact information
Contact Name:
Phone Number:
Relationship:
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15)
Are you enrolled in Medicare or Medicaid
Yes
No
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16)
How were you referred to this program?
Doctors office
Online ad
Newspaper ad
Friend or family member
Library or rec center
Agencies Website
Assisted Living
Home or Community Care center
Case Manager
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17)
Did your doctor, nurse, physical therapist or other health care provider suggest that you take this program?
Yes
No
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18)
What is the highest grade or level of school that you have completed?
Less than high school
Some high school
High school graduate or GED
Some college or vocational school
College graduate or higher
19)
Has a health care provider ever told you that you have any of the following chronic conditions (i.e., one that has lasted for three months or more)?
Arthritis or other bone/joint disease
High blood pressure/hypertension
Breathing/lung disease
Glaucoma/other chronic eye problem
Cancer
Osteoporosis
Depression
Parkinson's Disease
Diabetes
Other Chronic Condition(s) (specify):
Heart disease or blood circulation problem
Other (please specify)
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20)
Are you limited in any way in any activities because of physical, mental, or
emotional problems?
Yes
No
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21)
In general, would you say that your health is:
Excellent
Very good
Good
Fair
Poor
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22)
In the past 3 months, how many times have you fallen?
None
one or more times
Continue ONLY when finished. You will be unable to return or change your answers.