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About
Who Qualifies?
FAQ
Benefits
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About
Who Qualifies?
FAQ
Benefits
Get Started
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Get Started
Walking
Step
1
of
20
5%
How many medical condition(s) that affect your ability to Walk do you suffer from?
Condition 1 Name:
Condition 2 Name:
Condition 3 Name:
What best describes your Walking impairment?
I am unable to walk at all
I am able to Walk, it just takes me longer than the average person to do so
How much longer would it take you to walk the distance of 100m, or one city block?
Unable to walk
At least four times longer
At least three times longer
How often are you affected by your Walking conditions?
Rarely
Often
Always
What best describes your Walking restrictions? Please select all that apply.
I walk slowly
I need to stop walking and rest frequently
I have difficulty walking up/down an incline
I fall down frequently while walking
I have severe fatigue
I bump into objects
I limp when walking
I shuffle my feet when walking
I need assistance to walk
I am unable to walk
Other
What causes your restrictions?
Muscle weakness
Stiffness
Numbness
Fatigue
Limited range of motion
Balance issues
Poor motor skills
Shortness of breath
Dizziness
Pain
Swelling
Other
Are you on oxygen therapy?
Yes
No
Where do you experience pain?
Left ankle
Right ankle
Lower back
Upper back
Left foot
Right foot
Left hip
Right hip
Left knee
Right knee
Left leg
Right leg
Other
How frequently do you need to stop and rest while you are walking?
Unable to walk
Every couple of steps
Every 20 metres
Every half a block
Every block
Every 2 blocks
Do you use / have you used any devices to assist you in Walking?
Yes
No
What devices do you use?
Walking stick
Cane
Walker
Brace
Wheelchair
Scooter
Crutches
Back brace
Prosthetic limb
Other
Are you taking any medication that aids your Walking impairments?
Yes
No
What medications are you taking?
Are you currently receiving anything therapy or have you in the past?
Yes - I am currently receiving therapy
I have received therapy in the past
No - I have never received therapy to help treat my impairments
Please indicate the type of therapy that you receive
Physiotherapy
Chiropractic therapy
Massage therapy
Occupational therapy
Cortisone injection therapy
Botox
Nerve block therapy
Red light therapy
Other
Have you had any surgeries or procedures as a result of your impairments that affect your Walking?
Yes
No
How many surgeries / procedures have you had that affect your Walking?
1
2
3
4+
Please indicate what procedures you had done, and the year in which you had them
Do you have an accessible parking permit for your vehicle?
Yes
No
In what year did you get the accessible parking permit?
Have you had to make any significant changes to your home as a result of your condition?
Yes
No
Can you please describe what changes you have made to your home to accommodate your condition(s)? ie. Grab bars in the bathroom/shower, accessibility ramps, chair lift, bedside railing, etc.
Do you require assistance with household chores?
Yes
No
Is there any other information you wish to provide regarding how your Walking is affected on a daily basis?
