Wake Forest
Cary
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Wake Forest | 919.556.4678
Cary | 919.468.0955
New Patients
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Services
Physical Therapy
Ankle and Foot Pain
Arm, Wrist & Hand Pain
Chronic Pain Conditions
Elbow Pain
Gait Training
Head Pain & Discomfort
Hip Pain
Knee Pain
Physical Therapy (cont)
Neck & Spine Conditions
Pediatrics
Post-Amputation
Rehab of Neurological Conditions
Rehab of Total Joint Replacements
Shoulder Pain
Sports Injuries
Vestibular & Balance
Acoustic Neuroma
Concussion
Labyrinthitis
Vertigo
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Dry Needling
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Running & Gait Analysis
Sports Performance Series
Stretch Therapy
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Meet Our Clinicians
Kaela Bellefeuil, DPT, OCS
Olivier Chassin, DPT, Cert. DN
Tyler Clements, DPT
Jaime DelGenio, DPT, Cert. DN
Brian Gentile, PT, Cert. DN
Caitlin Goldsmith, DPT
Michael Holt McPherson, DPT
Grant Nelson, DPT, Cert. DN
Holly Schmitz, DPT
Heather Smith, DPT
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ABC Scale
Patient First Name
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Patient Last Name
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Date Of Birth
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MM slash DD slash YYYY
For each of the following activities, please indicate your level of self-confidence by choosing a corresponding number from the following rating scale:
0% - No Confidence | 100% - Complete Confident
How confident are you that you will not lose your balance or become unsteady when you…
Walk around the house?
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Walk up or down stairs?
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Bend over and pick up a slipper (or item) from the front of a closet floor?
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Reach for a small can off a shelf at eye level?
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Stand on your tiptoes and reach for something above your head?
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Stand on a chair and reach for something?
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Sweep the floor?
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Walk outside the house to a car parked in the driveway?
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Get into or out of a car?
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Walk across a parking lot to the mall (store)?
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Walk up or down a ramp?
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Walk in a crowded mall where people rapidly walk past you?
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Are bumped into by people as you walk through the mall?
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Step onto or off an escalator while you are holding onto a railing?
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Step onto or off an escalator while holding onto parcels such that you cannot hold onto the railing?
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Walk outside on icy sidewalks?
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Today's Date: 03/29/2023
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