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Want to get off the floor faster?

New Patient Form

Have you (or your loved one) had a fall in the past 6 months?

Single choice
Yes
No
Not sure

Are you currently able to get up from the floor independently?

Single choice
Yes, without difficulty
Yes, but it's challenging
No, I need help

Where do you currently live?

Single choice
Private home
Independent living
Assisted living
With family

Do you currently use any of the following?

Single choice
Cane
Walker
Wheelchair
None

If you could improve one thing right away, what would it be?

Who is filling out this form?

Single choice
Myself
Spouse
Adult Child
Caregiver
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