Balance and Falls Pre-Exam Form in Chapman
You have started planning around it. Which door you use, which shoes, whether the grass is wet, whether anyone is home. That is worth an examination, not an apology. Here are the questions your therapist will ask at our Chapman clinic, so you can think back before you arrive.
What your balance and falls pre-exam covers.
Staying upright is a committee decision. Your inner ear, your eyes, the sensation in the soles of your feet, the strength in your hips and the speed at which you can catch yourself all vote. When balance goes, it is usually because one member of that committee has quietly stopped showing up.
Which is why the questions get so specific. Read through them before your visit and answer what you can, out loud with a family member if that is easier. Nothing is submitted on this page. When you are ready to be seen, use the booking form further down.
Falls and near misses
How many times you have actually gone down in the past year, and what you were doing each time. Then the ones you would not call a fall: the grab at the counter, the catch on the door frame, the sit down that was really a controlled drop. Near misses tell us as much as falls do, so count them in.
Balance & gait disorders →What you hold on to now
A cane, a walker, a hand trailing the wall down the hallway, somebody’s elbow across a parking lot. Tell us what you use, when you started, and whether you use it everywhere or only away from home. If there is a device in the garage you refuse to touch, mention that as well.
Balance therapy →Where it feels worst
Gravel, wet grass, a sloped drive, curbs, stairs with no rail, a dark hallway in the middle of the night, turning quickly, reaching up into a high cupboard. Tell us which of those you now avoid, and whether the fear of falling has started choosing where you go and who you go with.
Request an appointment →Medications, vision and the house
Bring the medication list. Blood pressure tablets, sleep aids and anything that leaves you lightheaded when you stand all change the picture. Note recent vision changes, new glasses or eye surgery. Then take a lap of your own home: throw rugs, cords, a step down into the garage, dim lighting, a bathroom with nothing to grab.
Call (785) 922-4016 →What to bring to your first visit
- Your prescription, if a physician has already written you one
- Your driver’s licence or another photo ID
- Your insurance cards, or your Worker’s Comp or auto claim information
- A full list of your medications with the dosage and how often you take them
- Copies of any X-ray, MRI or CT reports related to a fall or an injury
- Your personal calendar, so we can schedule the rest of your visits before you leave
Wear the shoes you actually have on around the house. Kansas direct access means most patients can start physical therapy without a physician referral. Some insurance plans still require one for coverage, so we verify your specific plan before your first visit and tell you exactly where you stand.
Your Chapman clinic
Tues and Thurs, 7:20 am to 5:00 pm
You do not have to write a word of this down. Call (785) 922-4016 and answer it on the phone, or arrive a few minutes early and work through it with us at the front desk. Nobody is turned away for coming in empty handed. Bring the family member who witnessed the falls if you can, because they tend to remember what you do not. Use the form below to get on the schedule.