VIRTUAL MOB REGISTRATION FORM

    Virtual Matter of Balance Registration

    Do you have access to a device with a camera and audio?

    The Following questions will provide us with background information?

    What is your birthdate?

    Gender:

    Ethnicity:

    Race:Mark all that apply.

    Number of people in your Household:

    Is your household income less than $13,000 annually?

    Are you a veteran?

    Are you the spouce/widow of a veteran?

    Would you like to be included in our Lifescape Newsletters?

    Authorization Statement:
    I understand that my information will be used to register me for services at Lifescape Community Services, Inc. I understand that my personal information may be share with other organization for me to obtain assistance. I also understand that some personal information will be shared with government agencies or other organization for grant reporting purposes. Further, I authorize Lifescape to request and receive any information necessary for me to obtain services, including but not limited to confidential, financial, and medical reports.

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

    Are you limited in any way in any activities of physical, mental, or emotional problems?
    In general, would you say that your health is:

    The next few questions ask about falls. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.

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

    If you have fell in the past 3 months:

    How many of these falls caused an injury? (By injury we mean that fall caused you to limit your regular activities or at least a day or to go see a doctor.)

    Where did these fall(s) occur? (Please check all that apply)

    What happened after you feel and had an injury? (Please check all that apply)

    How fearful are you of falling?
    During the last 4 weeks, to what extent has your concern about falling interfered with your normal social activities with family, friends, neighbors or groups?
    I have made safety modifications in my home, such as installing grab bars or securing loose rugs, to reduce my risk of falling

    What best describes your activity level?

    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)?

    How Sure are you that: I can find a way to get up if I fall

    How Sure are you that: I can find a way to reduce falls

    How Sure are you that: I can protect myself if I fall

    How Sure are you that: I can increase my physical strength

    How Sure are you that: I can become steadier on my feet

    Please read the questions carefully and answer each one honestly, check if your answer is YES.

    If you answered YES to one or more questions - Talk with your doctor or nurse by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want - as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Find out which community programs are safe and helpful for you.