Thrive Survey
To better understand participation levels and improve services for individuals living with disabilities in the Greater Teton Valley initiated by Teton Physical Therapy & Rehabilitation in partnership with St. John's Health

Question Title

* 1. Contact information

Name *

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Date of Birth:

Date / Time

Date

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* 3. Diagnosis or Medical condition:

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* 4. I prefer to communicate by:

Question Title

* 5. In the last 6 months have you had an unplanned hospitalization?

Yes

Question Title

* 6. In the last 6 months have you participated in any of the below activities? (select multiple)

Sled Hockey

Adaptive road cycling

Adaptive mountain biking

Adaptive water sports

Individual fitness program or physical therapy

Power Up

Dance for Parkinson's

Boxing

Swimming

Adaptive downhill skiing

Adaptive cross-country skiing

Hunting or shooting

Therapeutic or Adaptive Horse Riding

Adaptive paragliding at Jackson Hole Mountain Resort

Via Ferrata at Jackson Hole Mountain Resort

Other (please specify)

None of the above

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* 7. If you answered none of the above to the previous question, what are your barriers to participation?

Question Title

* 8. Is there anything that would help improve your quality of life or well-being that you have not been able to access in the last 6 months?

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* 9. By checking yes, I authorize Teton Physical Therapy & Rehabilitation to release my survey responses that I have shared above to Teton Adaptive Sports and other partnering organizations in order to improve opportunities and steer future grant funding.

Yes

Question Title

* 10. I would like to be involved in or learn about: (select multiple)

Wheelchair seating and repair days

Group adaptive sports

Individual adaptive sports

Wellness classes

Education and guest speakers

Individual grants and funding

An annual wellness visit with a rehab team member to see if there is anything else I can be doing for my health.

Other (please specify)

None of the above

Thrive SurveyTo better understand participation levels and improve services for individuals living with disabilities in the Greater Teton Valley initiated by Teton Physical Therapy & Rehabilitation in partnership with St. John's Health

Question Title

* 1. Contact information

Question Title

* 2. Date of Birth:

Question Title

* 3. Diagnosis or Medical condition:

Question Title

* 4. I prefer to communicate by:

Question Title

* 5. In the last 6 months have you had an unplanned hospitalization?

Question Title

* 6. In the last 6 months have you participated in any of the below activities? (select multiple)

Question Title

* 7. If you answered none of the above to the previous question, what are your barriers to participation?

Question Title

* 8. Is there anything that would help improve your quality of life or well-being that you have not been able to access in the last 6 months?

Question Title

* 9. By checking yes, I authorize Teton Physical Therapy & Rehabilitation to release my survey responses that I have shared above to Teton Adaptive Sports and other partnering organizations in order to improve opportunities and steer future grant funding.

Question Title

* 10. I would like to be involved in or learn about: (select multiple)

Thrive Survey
To better understand participation levels and improve services for individuals living with disabilities in the Greater Teton Valley initiated by Teton Physical Therapy & Rehabilitation in partnership with St. John's Health