Not at all A little Somewhat A lot
Participant Post Program Survey
Today’s date: / /
M M 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)
Excelle
1. In general, would you say that your health is:
nt Very good Good Fair Poor
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.
2. Since this program began, how many times have you fallen? O times O none
If you fell since the program began:
a. 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
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
3. How fearful are you of falling?
4. Please mark the cir
cle that tells us how sure you are that you can do the
following activities.
How sure are you that:
Please turn this paper over and fill out the other side.
Somewhat
a. I can find a way to get up if I fall
O O
O
O O
b. I can find a way to reduce falls
O O O
I can protect myself if I fall
O O O O
d. I can increase my physical strength
O O O O
e. I can become more steady on my feet
O O O O
