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Fall Risk Prevention Day
Event Timing: January 26, 2023 9:00 am - 1:00 pm
Event Address: Hopkinton Senior Center
Contact us at (508) 521-8829
PLEASE BRING A COPY OF ALL MEDICATION AND YOUR PRIMARY CARE PROVIDER NAME AND PHONE NUMBER
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Phone Number
*
Your answer
Do you have a history of falling?
*
Yes
No
When was that last time that you fell?
*
Less than 1 week ago
Less than 1 month ago
Less than 6 months ago
More than 1 year ago
Does not apply, I have never fallen
Were you injured from a fall?
Yes
No
Clear selection
Are you afraid of falling ?
No
Yes
Other:
Clear selection
Please choose an appointment time
*
11:00
11:20
11:40
12:00
Other:
Send me a copy of my responses.
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