Physical Therapy Class Completion Form

Please complete the following questions to receive credit for completing the physical therapy class.

First Name:

Last Name:

Date of birth:

Email:

*If you do not have an email, what is the best way to contact you?*

Are you dependent on oxygen?:

Yes
No

Are you dependent on a wheelchair?:

Yes
No

Are you dependent upon a walker, cane or crutch?:

Yes
No

Do you have any significant shortness of breath while bathing, dressing, or other basic daily tasks? (for example, do you require the assistance of adaptive equipment or the assistance of another person to help with bathing and/or dressing):

Yes
No

Verification:

Enter security code:

Northern Light Eastern Maine Medical Center

Northern Light Eastern Maine Medical Center

7 - Physical Therapy Class Completion Form

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Northern Light Eastern Maine Medical Center

Northern Light Eastern Maine Medical Center

7 - Physical Therapy Class Completion Form

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