Do You Qualify?

Do you sometimes feel left out by not being able to go out with your friends or family?: Yes No
Do you have health related issues that limit your mobility?: Yes No
Are you having trouble getting to your kitchen or dining facility by yourself for a meal?: Yes No
Is it difficult for you to get to the bathroom on your own?: Yes No
Do you have difficulty accessing your clothes and getting dressed every day?: Yes No
Have you lost the ability to operate a manual wheelchair inside your home?: Yes No
Are you feeling like a bother to others due to your limited mobility?: Yes No
Have you fallen in the past 12 months?: Yes No

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Patients