Post-Drums Alive Class Survey

What is today's date? *

(MM/DD/YYYY)

Enter your birthday *

(MM/DD/YYYY)

Name

First Last

Phone

Email *

How often do you exercise at home? *

How often are you active? *

How often are you sad or blue? *

How often do you gather with family/friends? *

How often do you fall? *

Pain Scale

How would you rate your current level of pain? Enter number between 0 and 10 (0 is no pain ; 10 is worst pain)

Please enter a number from 0 to 10.

How has participating in Drums Alive made a difference in your life?