VIRTUAL MOB REGISTRATION FORM

Gender:

MaleFemalePrefer Not to Say

Ethnicity:

Not Hispanic or LatinoHispanic or Latino

Race:Mark all that apply.

American Indian or Alaska NativeNative Hawaiian or other Pacific IslanderAsianWhiteBlack or African AmericanHispanic, Latino, or Spanish

Number of people in your Household:

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

YesNo

Are you a veteran?

YesNo

Are you the spouce/widow of a veteran?

YesNo

Would you like to be included in our Lifescape Newsletters?

YesNo

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.

I Authorize that I have read the above statement and accept these conditions.

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

YesNo

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

YesNo

In general, would you say that your health is:

ExcellentVery GoodGoodFairPoor

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

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)

IndoorsOutdoorsBoth Indoors and Outdoors

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

Went to the emergency room.Was admitted to hospital.Visited my primary physician.Did not seek medical care.

How fearful are you of falling?

Not at allA littleSomewhatA lot

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?

ExtremelyQuite a bitModeratelySlightlyNot at all

I have made safety modifications in my home, such as installing grab bars or securing loose rugs, to reduce my risk of falling

TrueFalse

What best describes your activity level?

Vigorously active for at least 30 min, 3 times per weekModerately active at least 3 times per weekSeldom active, preferring sedentary activities.

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 diseaseHigh blood pressure/hypertensionBreathing/lung disease Glaucoma/ or any other chronic eye problemCancerOsteoporosisDepressionParkinson’s DiseaseDiabetesHeart disease or blood circulation problemOther Chronic Condition(s)

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

Very SureSureSomewhat SureNot Sure At All

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

Very SureSureSomewhat SureNot Sure At All

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

Very SureSureSomewhat SureNot Sure At All

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

Very SureSureSomewhat SureNot Sure At All

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

Very SureSureSomewhat SureNot Sure At All

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

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?2. Do you feel pain in your chest when you do physical activity?3. In the past month, have you had chest pain when you were not doing physical activity?4. Do you lose your balance because of dizziness or do you ever lose consciousness?5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?7. Do you know of any other reason why you should not do physical activity?

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.