Hemiparesis Assessment Survey
Please complete this survey to help assess the symptoms and daily impact of hemiparesis.
Full Name
*
First Name
Last Name
Email Address
example@example.com
Which side of your body is primarily affected?
*
Left Side
Right Side
Both Sides
Not Sure
How would you rate the severity of your muscle weakness?
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
How much does hemiparesis affect your ability to perform daily activities?
*
Not at all
A little
Moderately
Severely
Do you use any mobility aids? (Select all that apply)
Cane
Walker
Wheelchair
None
Other
How long have you been experiencing hemiparesis? (e.g., 6 months, 2 years)
Please provide any additional comments or information regarding your condition.
Submit Assessment
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