Abilene Balance/Falls

Balance/Falls Pre-Exam Form
Abilene Location

For patients experiencing balance difficulties and/or falls. Please fill out to the best of your ability and submit.

* Indicates required field

Name *

First

Last

INSTRUCTIONS: On a scale of 0 to 10, how confident are you that you can do each of these activities without falling, with 0 meaning "not confident/not sure at all", 5 being "fairly confident/fairly sure", and 10 being completely sure"? *

If you have stopped doing the activity at least partly because of being afraid of falling, score a 0; If you have stopped an activity purely because of a physical problem, leave that item blank If you do not currently do the activity for other reasons, please rate that item based on how you perceive you would rate if you had to do the activity today. *

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now With 2 Locations to Better Serve You!

103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8:00 a.m - 5:00 p.m.

1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Monday - 1 p.m. - 5 p.m.
Tuesday & Thursday 8 a.m. - 5 p.m.

The state of Kansas is a “Direct Access” state for Physical Therapy. ​ You can begin physical therapy with or without a referral from a physician. ​

Now With 2 Locations to Better Serve You!

Contact Us

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.