[ProgramName]ParticipantInformation Form
Today’sdate: / /
M MD DYYY Y
ParticipantI.D.____ /____/____(firsttwolettersofyourfirstname,firsttwolettersofyourlastname, lasttwonumbersofyourbirthyear)
1.Didyour doctor,nurse, physicaltherapistorotherhealthcareprovidersuggestthatyou takethisprogram?
OYesONo
2.How oldareyoutoday? years
3.Doyoulive alone?OYesONo
4.Areyou:OMale orOFemale?
5.AreyouofHispanic,Latino, orSpanishorigin?OYesONo
6.Whatis yourrace?Checkall thatapply.
O AmericanIndian orAlaskaNative
O Asian
O Blackor AfricanAmerican
O NativeHawaiianorotherPacific Islander
OWhite
7.Whatis thehighest grade orlevelof schoolthat youhave completed?
O Lessthan highschool
O Somehighschool
O Highschool graduate or GED
O Somecollege or vocational school
O Collegegraduate or higher
8. Hasahealthcareproviderevertold youthatyouhaveanyofthefollowingchronic conditions (i.e., one that has lasted for three months or more)?Check Yes or No.
Arthritis or other bone/joint disease / YesNo / High blood pressure/hypertension / YesNoBreathing/lung disease / Yes No / Glaucoma/other chronic eye problem / Yes No
Cancer / Yes No / Osteoporosis / YesNo
Depression / Yes No / Parkinson’s Disease / YesNo
Diabetes / Yes No / Other Chronic Condition(s) (specify): / ______
Heart disease or blood circulation problem / Yes No
9. Are you limited in any way in any activities because of physical, mental, or
emotional problems? O YesONo
Pleaseturnthispaperoverandfillouttheotherside.
10. Ingeneral,wouldyousaythatyourhealthis:
ExcellentVerygoodGoodFairPoor
Thenext fewquestionsask aboutfalls.Byafall,wemeanwhenaperson unintentionally comestorestonthegroundoranotherlowerlevel.
11.Inthepast3 months, howmanytimes haveyoufallen?OnoneO times
If you fell in the past 3 months:
a. howmanyofthesefallscausedaninjury? (Byan injurywemeanthefallcausedyoutolimityourregularactivitiesforatleastadayortogoseea doctor.)
numberoffallscausinganinjury
b. where did the fall(s) occur (Please check all that apply)?
Indoors Outdoors Both indoors and outdoors
c. what happened after you fell and had an injury? (Please check all that apply)
Went to the Emergency Room Was admitted to the hospital
Visited my Primary Care Physician Did not seek medical care______
12.Howfearfulare youoffalling?
Not atallAlittleSomewhatAlot
13.Pleasemarkthecirclethattellsushowsureyouarethatyoucandothe followingactivities.
How sure are you that:
Very Sure / Sure / Somewhat sure / Not at all surea.Icanfindawaytoget upifIfall / O / O / O / O
b.Icanfindawaytoreducefalls / O / O / O / O
c.Ican protectmyselfifIfall / O / O / O / O
d.Icanincreasemyphysicalstrength / O / O / O / O
e. I can become more steady on my feet / O / O / O / O
14. Duringthelast4weeks,towhatextenthasyourconcernaboutfallinginterfered withyournormalsocialactivitieswithfamily,friends,neighborsorgroups?
ExtremelyQuitea bitModeratelySlightlyNotatall
15. I have made safety modifications in my home, such as installing grab bars or securing loose rugs, to reduce my risk of falling __True __ False
16. What best describes your activity level?
OVigorously active for at least 30 min, 3 times per week
O Moderately active at least 3 times per week
OSeldom active, preferring sedentary activities