2 Participant Information

[Program Name] Participant Information Form
Today’s date:

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M M

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D D

Y

Y

Y

Y

Participant I.D. (first two letters of your first name, first two letters of your last name,
last two numbers of your birth year): __ __ __ __ __ __
1. Did your doctor, nurse, physical therapist or other health care provider suggest that you
take this program?
O Yes

O No

2. In general, would you say that your health is:
Excellent

Very good

3. How old are you today?
4. Do you live alone? O Yes

Good

Fair

Poor

years
O No

5. Are you: O Male or O Female ?
6. Are you of Hispanic, Latino, or Spanish origin? O Yes

O No

7. What is your race? Check all that apply.
O
O
O
O
O

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

8. What is the highest grade or level of school that you have completed?
O
O
O
O
O

Less than high school
Some high school
High school graduate or GED
Some college or vocational school
College graduate or higher

9. Are you limited in any way in any activities because of physical, mental, or
emotional problems?
O Yes

O No
Please turn this paper over and fill out the other side.

Participant Information Form (continued)
The next few questions ask about falls. By a fall, we mean when a person unintentionally
comes to rest on the ground or another lower level.
10. In the past 3 months, how many times have you fallen? O none O

times

a. If you fell in the past 3 months, how many of these falls caused an injury? (By an
injury we mean the fall caused you to limit your regular activities for at least a day or to go see a
doctor.)
number of falls causing an injury

11. How fearful are you of falling?
Not at all

A little

Somewhat

A lot

12. Please mark the circle that tells us how sure you are that you can do the
following activities.
How sure are you that:

Very sure

Sure

Not at
all
sure

Somewhat
sure

a. I can find a way to get up if I fall
b. I can find a way to reduce falls
c. I can protect myself if I fall
d. I can increase my physical strength
e. I can become more steady on my
feet

13. During the last 4 weeks, to what extent has your concern about falling interfered
with your normal social activities with family, friends, neighbors or groups?
Extremely

Quite a bit

Moderately

Slightly

Not at all

14. Has a health care provider ever told you that you have any of the following chronic
conditions (i.e., one that has lasted for three months or more)? (Please check all
that apply.)
Arthritis or other bone/joint disease

Heart disease or blood circulation problem

Breathing/lung disease

Glaucoma/ other chronic eye problem

Depression

Other chronic condition:

Diabetes

None (No chronic conditions)