Assessment Questionnaire

Please fill out the following form prior to an assessment meeting.

Contact Details

Full name

Mobile Phone

Home Phone

Age

Profession

Country

Timezone

State (optional)

Parkinson History

Since when do yo have Parkinson?

Please detail your medications and frequencies

What are your physical handicaps and limitations?

What is your physchological condition as affected by Parkinson?

What physical activity do you engage in to improve your condition?

What are your expectations? How would you like to see yourself after taking responsibility for your physical condition?

Select an option

By checking this box you understand that making physical behavior changes requires hard work; It is your responsibility to put hard work into the process, and our responsibility to give you all required tools.

Thanks for submitting!