PD survey - Emeritus Health

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Parkinson's Disease Survey

Thank you very much for taking the time to complete this important survey.

* Indicates required field

How old are you? *

Less than 13 13-18 19-25 26-35 36-50 Over 50 Prefer not to say

What is your gender? *

Male Female

What is your ethnicity? *

When were you diagnosed with Parkinson's Disease? *

Are you concerned that you (or your loved one) may lose their balance and/or fall? *

Yes No

Have you fallen in the last year? *

Yes No

Have you fallen in the last month? *

Yes No

How many times have you fallen in the last year? *

Everyday at least once per week 2 to 3 times per week Once per month Once per six months More than once per six months Once per 12 months

Have you participated or tried any balance programs or physical therapy to improve your balance? *

Yes No

How would you rate your balance on a scale of 0-10? *

(0 = worst, 10 = BEST)

Name *

First

Last

Email *

Comment *

Submit

Emeritus Health

PO Box 111785
Naples FL 34108
CWilliams@EmeritusHealthFitness.com
239-287-5376