Emergency Contact Information
Do you have a Movement Disorder Specialist? If yes, Please share name and contact information If possible. Your last visit was
Have you had Physical Therapy? If yes, where and when
Have you had Occupational Therapy, If yes, where andwhen
Have you had Speech Therapy? If yes, where and when
What Parkinson's related symptoms are you experiencing?
Which symptoms are you experiencing? (check all that apply) Tremors - if yes, which side is most affected? RIGHT LEFT BOTH
Postural changes Leaning forward? Leaning sideways
Vision impairment Double Vision Blurred Vision Tired Eyes
Do you take medications for Parkinson's related symptoms? Please listnames, dosages and times you take them names, dosages and times names, dosages and times names, dosages and times names, dosages and times
Other Health Questions
Pre-Participation Screening Questionnaire/ Health Fitness Facility
Other heart condition (specify) Type a label
(FOR OFFICE USE ONLY)Notes and questions for test administrator
I name (member name) allow Rock Steady Boxing to publish orbroadcast my image/likeness and/or name for promotional purposes associated with RockSteady Boxing.