Your details ^*

First Name

Last Name

Email ^*

Phone Number

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What gender are you?

Male

Female

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How old are you?

60-70

70-80

80+

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Do you struggle with tasks you were fine with?

Yes

No

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Does standing up take more effort than you'd like?

Yes

No

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Have jars been harder to open recently?

Yes

No

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Can you go for a 1 hour walk without feeling exhausted?

Yes

No

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Could you do 5 press ups?

Yes

No

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Are your legs weaker than you'd like?

Yes

No

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Do you currently partake in regular exercise?

2+ times/week

Yes

No

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Can you go for a 1 hour walk without being exhausted?

Yes

No

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Are your legs weaker than you'd like?

Yes

No

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Does standing up take more effort than it used to?

Yes

No

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Have jars been harder to open recently?

Yes

No

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Do you have any ongoing joint pain?

Yes

No

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Does falling concern you?

Yes

No

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Do you currently partake in regular exercise?

2+ times/week

Yes

No

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Are you tripping more often than you’d like?

Yes

No

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Does falling concern you?

Yes

No

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Can you confidently walk up a flight of stairs?

Yes

No

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Are everyday tasks more difficult than you’d like?

Yes

No

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Can you walk for 45 minutes without being exhausted?

Yes

No

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Do you have any ongoing joint pain?

No

Yes

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Do you currently partake in regular exercise?

(2+ times/week)

Yes

No

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Can you walk for 30 minutes without being exhausted?

Yes

No

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Have you had any knee/hip replacements?

Yes

No

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Are you currently doing any regular exercise?

Yes

No

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Have you been diagnosed with a neurological conditions?

Yes

No

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Have you had a fall in the last 6 months?

Yes

No

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Are you concerned with your balance?

Yes

No

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Are everyday tasks more difficult than you’d like?

Yes

No

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Are your legs weaker than you would like?

Yes

No

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Do you have osteoporosis?

Yes

No

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Does standing up take more effort than you’d like?

Yes

No

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Have you had a fall in the last 6 months?

Yes

No

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Do you have any ongoing joint pain?

Yes

No

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Can you walk for 45 minutes without being exhausted?

Yes

No

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'Oops! something went wrong.',

Do you currently partake in regular exercise?

(2+ times/week)

Yes

No

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Are everyday tasks more difficult than you’d like?

Yes

No

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'Oops! something went wrong.',

Can you walk for 30 minutes without being exhausted?

Yes

No

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'Oops! something went wrong.',

Have you had any knee/hip replacements?

Yes

No

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'Oops! something went wrong.',

Are you currently doing any regular exercise?

Yes

No

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Have you been diagnosed with a neurological conditions?

Yes

No

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