7 - Physical Therapy Class Completion Form

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




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

Are you dependent on oxygen?:


Are you dependent on a wheelchair?:


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


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):


Enter security code:
 Security code