FY13 Free From Falls Screening Application

 
Free From Falls: A Comprehensive Fall Prevention Programs for People With MS
Free from Falls is an exciting new 8-session series focusing on falls and multiple sclerosis. This program is designed for individuals that are able to walk unassisted for 10-15 steps, alone or with one cane, walking stick or crutch. Each session is 2-hours and will have two parts; a discussion component and exercise component. You will learn how to minimize different hazards and fall risks, how to make changes to daily activities to conserve energy and build confidence, to safely enjoy activities. You will work with physical therapists and occupational therapists to increase your balance, stability, endurance, strength, environment, confidence and safety.
There is a $20 fee to participate in the program; financial aid is available.
Please note that this application is private. It will only be seen by the Program Managers of the Free From Falls Program
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1. Name:
2. Date:
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3. Please fill in your address information below:
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4. Please fill in the information below:
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5. Gender:
6. Date of Birth:
7. Date of MS diagnosis:
8. Do you currently participate in regular physical exercise
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9. Have you fallen in the last 6 months?
10. If yes, how many times?
11. How many times have you fallen in the past year?
12. I am concerned about falling?
13. I can ambulate/walk independently
14. I use an assistive device to ambulate/walk inside my home.
15. I use an assistive device to ambulate/walk outdoors.
We will need you to fill out a medical release form from one of your doctors verifying that you are under his/her care and can participate in a Physical Therapy program. This medical waiver will be emailed to you once we receive your survey.
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16. This program will meet for 8 sessions; 2 times a week for 4 weeks.

I am registering for this course with the knowledge that it meets 2 times a week , for 4weeks, and am committed to attending all of the sessions.
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