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DREEVEN Survey
Thank you so much for your interest in DREEVEN!
We are committed to providing you with the best possible support. This form will help us better understand your situation, so we can offer you a faster and more personalized response.
What is your first name?
*
What is your last name?
*
What is your email?
*
What is your age?
*
What is your height?
(Please specify the unit)
*
What is your weight?
(Please specify the unit)
*
In which country do you live?
*
In which state do you live?
*
In which city do you live?
*
What is your condition?
*
What is your condition?
A
Stroke
B
Multiple Sclerosis
C
Cerebral Palsy
D
Spinal Cord Injury
E
Other (please specify)
What kind of health insurance plan do you have?
*
What is the name of your health insurance provider?
Do you rely on a caregiver?
*
Do you rely on a caregiver?
A
Yes
B
No
Do you rely on a mobility assistance device?
*
Do you rely on a mobility assistance device?
A
Yes
B
No
What daily activities would you like to do the most?
*
What daily activities would you like to do the most?
Take a walk around your neighborhood
Go grocery shopping
Enjoy a hike in nature
Do some housework or chores
Other
Have you fallen in the last 6 months?
*
Have you fallen in the last 6 months?
A
Yes
B
No
Do you have spasticity?
*
Do you have spasticity?
A
None
B
Low
C
Medium
D
Severe
How much time do you spend walking every day?
*
Which
upper
body
movements do you find the most challenging?
*
Which
lower
body
movements do you find the most challenging?
*
How often do you have to walk over obstacles or uneven terrain
*
How often do you have to walk over obstacles or uneven terrain
0
1
2
3
4
5
Not often
Very often
Do you regularly carry a bag?
*
Do you regularly carry a bag?
A
Yes
B
No
Do you use an adapted car or vehicle?
*
Do you use an adapted car or vehicle?
A
Yes, I use an adapted car or vehicle
B
No, I use a regular car or vehicle
C
I do not drive
Would you be willing to answer a few questions about your physical therapy experience in this online form? Your answers will help us better understand your profile.
*
Would you be willing to answer a few questions about your physical therapy experience in this online form? Your answers will help us better understand your profile.
A
Yes
B
No
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