A Matter of Balance-Virtual or In-Person

Which Workshop would you like to register for?

First Name:

Last Name:


*5)Date of Birth


Phone Number including area code (555-555-5555)



Marital Status

Do you live alone?

Do you consider yourself low income?

Monthly Income

*14)Emergency Contact information

Are you enrolled in Medicare or Medicaid

How were you referred to this program?

Did your doctor, nurse, physical therapist or other health care provider suggest that you take this program?

What is the highest grade or level of school that you have completed?

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)?

Are you limited in any way in any activities because of physical, mental, or
emotional problems?

In general, would you say that your health is:

In the past 3 months, how many times have you fallen?

Continue ONLY when finished. You will be unable to return or change your answers.