| Do you use the table for support when rising to standing?
: |
Yes
No |
| Are you having trouble putting your socks on? : |
Yes
No |
| Is turning in bed creating a challenge? : |
Yes
No |
| If you been given a diagnosis, please state : |
|
| If there was an emergency situation in the building
could you use the stairs? : |
Yes
No |
| What mobility aids do you require? : |
|
| Is your mobility situation deteriorating? : |
Yes
No |
| Are you the : |
|
| What level of support are you currently getting? :
|
|
| Would you be interested in : |
|
| Country of residence, so I know what time zone I should
be working in : |
|
| Would you be interested in receiving our regular newsletter?
: |
Yes
No |