A Matter of Balance-Virtual (AMOB-V)

*1)
Which Workshop would you like to register for?

*2)
First Name:


*3)
Last Name:


*4)
Gender

*5)Date of Birth



*6)Address





*7)
Phone Number including area code (555-555-5555)


*8)
Ethnicity

*9)
Race

*10)
Marital Status

*11)
Do you live alone?

*12)
Do you consider yourself low income?

*13)
Monthly Income

*14)Emergency Contact information



*15)
Are you enrolled in Medicare or Medicaid

*16)
How were you referred to this program?

*17)
Did your doctor, nurse, physical therapist or other health care provider suggest that you take this program?

*18)
What is the highest grade or level of school that you have completed?

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)?

*20)
Are you limited in any way in any activities because of physical, mental, or
emotional problems?

*21)
In general, would you say that your health is:

*22)
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.