Our commitment to providing the highest levels of care means that our team includes only therapists and registered nurses. We feel strongly that full-fledged therapists and registered nurses, who are qualified and licensed to assess the changing needs of clients, best serve continuity and quality of care. Our clients’ needs are best served by our team approach and innovative relationships from research with top-notch universities and residency program-one of the first in the nation.
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Free Health Assessment Questionnaire

Please fill out the following information so that we can contact you regarding your free assessment.
*Boxes in red are required.

Full Name:
I am: The Patient Family Member/POA Healthcare Professional
Address:
City: State: Zip:
Email Address:
Contact Phone:
I/my family member/my Patient have issues with the following:  Yes
I have had a fall
I am unsteady on my feet
I have pain that affects my quality of life
Wound care questions
Diabetic teaching questions
Blood draw questions
I’m having difficulty with performing activities of daily living safely
I need a new walker or wheelchair
Foley care questions
I don’t walk right anymore
My balance is off
I am dizzy (Vestibular Assessment)
I choke or cough when I eat or drink something
I have trouble chewing food
I forget to take my medications
I am on thickened liquids
I have had pneumonia two times or more in the last three months
I have had significant weight loss in the last three months
I have trouble getting dressed daily
I have trouble bathing independently
I have trouble setting up my medications
   
I am interested in the following programs:  
Post surgical rehabilitation
Parkinson’s rehabilitation
Stroke Rehabilitation
Cardiac Rehabilitation Program
Osteoporosis Program
Incontinence Program
Home Safety Assessments
Swallowing Evaluations
   
Additional Comments: