Clinic Customer Intake - Forged Amputee Wellness

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Date of Birth(Required)

Email(Required)

Level of Amputation(Required)

Above Knee

Below Knee

Other

Prosthesis Wear(Required)

Activities(Required)

Please check the activities that you are able to do safely and independently (without an assistive device).

Walk 50 feet

Stand to do personal care activities (brush teeth, wash face, etc.) without holding on to something

Bend down to pick a small item off the floor without use of hand support

Stand up from a chair without pushing through your arms

Rolling over and going from a lying position to sitting on the edge of your bed

Other(Required)

Do you currently have any other medical conditions or co-morbidities that will affect your ability to exercise that we should be aware of?

In order to help me make your experience as personalized as possible, please tell me a little more about yourself and your current situation. I would love to learn more about you including your reasons for joining Forged. Feel free to be as brief or detailed as you would like.(Required)

Clinic User Signup!

Stay Strong, Stay Informed

FORGED Amputee Wellness