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Falls Prevention Course Enquiry Form
Falls Prevention Course Enquiry Form
Alexander Costello
2020-01-30T12:25:22+00:00
Falls Prevention Enquiry Form
Please complete the following information to register your interest in Falls Prevention Course and to enable the Physiotherapist to accurately assess your ability level. All information provided will be treated in line with our Privacy Policy.
Which course suits you?
January 2019
March 2019
May 2019
June 2019
September 2019
Participant Name
*
First
Last
Participant DOB
*
What would the participant like to gain from the course?
Contact telephone number
*
Who's number is this?
*
Address
*
Street Address
Post Code
Email
*
Enter Email
Confirm Email
About your mobility
Please describe your mobility as accurate as you can
Please select the option which best describes your mobility
*
I can walk independently without assistance
I can walk independently with a walking aid
I use assistance of relative/support worker/carer
I am full time wheelchair user/ I am unable to walk
I am able to stand up from the wheelchair without assistance
Can you walk independently...
Indoors
Outdoors
Both
walk independently with a walking aid
Inside
Outside
Both
If any, which walking aids do you use?
Falls
Have you fallen in the last 6 months?
Yes
No
Have you recently developed a fear of falling, even though you have never fallen?
Yes
No
Any other information?
Feel free to make us aware of any other information you think is relevant.
Please give details here.
Payment Information
The cost of the 6-week course is £48.00. Payment is required prior to starting the course. We will send out an invoice by using the details you have submitted. We send invoices via email. If you would like the invoice sending to an alternative address please indicate below.
Email
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