{"id":9613,"date":"2024-06-26T16:10:06","date_gmt":"2024-06-26T21:10:06","guid":{"rendered":"https:\/\/uamscaregiving.org\/springdale\/?p=9613"},"modified":"2024-08-07T10:40:03","modified_gmt":"2024-08-07T15:40:03","slug":"essentrics-pre-survey","status":"publish","type":"post","link":"https:\/\/uamscaregiving.org\/springdale\/2024\/06\/26\/essentrics-pre-survey\/","title":{"rendered":"Essentrics Pre-Survey"},"content":{"rendered":"<p>Essentrics draws on the flowing movements of Tai-Chi which create health and balance and the healing principles of physiotherapy creating a pain free body.<\/p>\n<p>&nbsp;<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_105' style='display:none'>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_105'  action='\/springdale\/wp-json\/wp\/v2\/posts\/9613' data-formid='105' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_105' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_105_23\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_23\" ><label class='gfield_label gform-field-label' for='input_105_23'>What is today&#039;s date?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_105_23'><strong><i>(MM\/DD\/YYYY)<\/i><\/strong><\/div><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_105_23_dmessage' name='input_23' id='input_105_23' type='text' value='04\/25\/2026' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_105_23_date_format gfield_description_105_23\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_105_23_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_105_23' class='gform_hidden' value='https:\/\/uamscaregiving.org\/springdale\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_105_18\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_18\" ><label class='gfield_label gform-field-label' for='input_105_18'>Enter your birthday<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_105_18'><strong><i>(MM\/DD\/YYYY)<\/i><\/strong><\/div><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_105_18_dmessage' name='input_18' id='input_105_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_105_18_date_format gfield_description_105_18\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_105_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_105_18' class='gform_hidden' value='https:\/\/uamscaregiving.org\/springdale\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_105_45\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_105_45\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_105_45'>\n                            \n                            <span id='input_105_45_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_45.3' id='input_105_45_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_105_45_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_105_45_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_45.6' id='input_105_45_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_105_45_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/fieldset><div id=\"field_105_49\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_105_49\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_105_49'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_49' id='input_105_49' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_105_50\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_105_50\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_105_50'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_50' id='input_105_50' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_105_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_21\" ><legend class='gfield_label gform-field-label' >How are you participating?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_21'>\n\t\t\t<div class='gchoice gchoice_105_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='In-person'  id='choice_105_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_21_0' id='label_105_21_0' class='gform-field-label gform-field-label--type-inline'>In-person<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='via Zoom'  id='choice_105_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_21_1' id='label_105_21_1' class='gform-field-label gform-field-label--type-inline'>via Zoom<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_105_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_25\" ><legend class='gfield_label gform-field-label' >How often do you exercise at home?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_25'>\n\t\t\t<div class='gchoice gchoice_105_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='4'  id='choice_105_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_25_0' id='label_105_25_0' class='gform-field-label gform-field-label--type-inline'>All the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='3'  id='choice_105_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_25_1' id='label_105_25_1' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='2'  id='choice_105_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_25_2' id='label_105_25_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='1'  id='choice_105_25_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_25_3' id='label_105_25_3' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_105_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_40\" ><legend class='gfield_label gform-field-label' >How often are you active?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_40'>\n\t\t\t<div class='gchoice gchoice_105_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='4'  id='choice_105_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_40_0' id='label_105_40_0' class='gform-field-label gform-field-label--type-inline'>All the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='3'  id='choice_105_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_40_1' id='label_105_40_1' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_40_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='2'  id='choice_105_40_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_40_2' id='label_105_40_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_40_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='1'  id='choice_105_40_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_40_3' id='label_105_40_3' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_105_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_41\" ><legend class='gfield_label gform-field-label' >How often are you sad or blue?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_41'>\n\t\t\t<div class='gchoice gchoice_105_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='4'  id='choice_105_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_41_0' id='label_105_41_0' class='gform-field-label gform-field-label--type-inline'>All the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='3'  id='choice_105_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_41_1' id='label_105_41_1' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='2'  id='choice_105_41_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_41_2' id='label_105_41_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_41_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='1'  id='choice_105_41_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_41_3' id='label_105_41_3' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_105_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_42\" ><legend class='gfield_label gform-field-label' >How often do you gather with family\/friends?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_42'>\n\t\t\t<div class='gchoice gchoice_105_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='4'  id='choice_105_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_42_0' id='label_105_42_0' class='gform-field-label gform-field-label--type-inline'>All the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='3'  id='choice_105_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_42_1' id='label_105_42_1' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_42_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='2'  id='choice_105_42_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_42_2' id='label_105_42_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_42_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='1'  id='choice_105_42_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_42_3' id='label_105_42_3' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_105_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_43\" ><legend class='gfield_label gform-field-label' >How often do you fall?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_105_43'>\n\t\t\t<div class='gchoice gchoice_105_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='4'  id='choice_105_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_43_0' id='label_105_43_0' class='gform-field-label gform-field-label--type-inline'>All the time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='3'  id='choice_105_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_43_1' id='label_105_43_1' class='gform-field-label gform-field-label--type-inline'>Often<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_43_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='2'  id='choice_105_43_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_43_2' id='label_105_43_2' class='gform-field-label gform-field-label--type-inline'>Sometimes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_105_43_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='1'  id='choice_105_43_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_105_43_3' id='label_105_43_3' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><div id=\"field_105_52\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_52\" ><label class='gfield_label gform-field-label' for='input_105_52'>Pain Measurement Scale<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_105_52'>Please enter a number between 0 and 10 to indicate your current level of pain.  (0=no pain; 10=worst pain possible)<\/div><div class='ginput_container ginput_container_number'><input name='input_52' id='input_105_52' type='number' step='any' min='0' max='10' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_105_52 gfield_description_105_52\" \/><div class='gfield_description instruction ' id='gfield_instruction_105_52'>Please enter a number from <strong>0<\/strong> to <strong>10<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_105_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_105_51\" ><legend class='gfield_label gform-field-label' >Follow Up<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_105_51'><strong><i>We would like to follow up with you in six-weeks to evaluate your progress.  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