• 1700 SW 7th Street, Topeka, Kansas 66606-1690
  • 785-295-8000

Stroke Leap Event Registration

General Information
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mm/dd/yyyy
Location of Stroke:


Current Age:





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Gender:

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Effects of Stroke

Check all that apply to you.

Paralysis/weakness on RIGHT side of body:

If yes:

Paralysis/weakness on LEFT side of body:

If yes:

Problems with short-term memory:

Difficulty expressing self with:

Difficulty understanding:

Any difficulty with vision:

Any emotional problems:

Do you use a:




Will someone be attending with you?

Name, Relationship
Do you have dietary restrictions?

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