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About Us
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FAQ
Contact
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Customer
Intake Form
Step 1:
Complete the Customer Intake Form
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Email
(Required)
Level of Amputation
(Required)
Above Knee
Below Knee
Other
Prosthesis Wear
(Required)
Daily prosthesis wearer for high level activities (hiking, running, climbing, etc.).
Daily prosthesis wearer for community ambulation and lower level activities (walking for exercise, light weight lifting, etc.).
Daily prosthesis wearer with ambulation mostly within the home.
Daily prosthesis wearer with minimal ambulation.
Minimal or no prosthesis wear time.
Activities
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
Please check the activities that you are able to do safely and independently (without an assistive device).
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)
Consent
I agree to the participation policy.
I acknowledge that I am voluntarily participating in the fitness program(s) provided by FORGED Amputee Wellness. I understand that physical exercise, by its very nature, carries with it certain inherent risks, including but not limited to physical injury, strain, discomfort, and even the possibility of serious injury or death. By signing up for this program I hereby assume all risks and responsibility for any such injuries or other medical incidents and will not hold FORGED liable for any of the above.
Name
This field is for validation purposes and should be left unchanged.
