TCA/FP First Session Survey TCA/FP First Session Survey OMB Control No. 0985-0039 Exp. date 03/31/2021 By filling out this form, I agree that the information collected on program forms may be studied and shared, with no way to link it back to me. Today's Date: MM slash DD slash YYYY Participant ID: ____ ____ / ____ ____ / ____ ____ (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? YES NO 2. How old are you today? ____________ years 3. Do you live alone? YES NO 4. Are you male or female? MALE FEMALE 5. Are you of Hispanic, Latino, or Spanish origin? YES NO 6. What is your race? Check all that apply. Hold shift key and click to multi-select.American Indian or Alaska NativeBlack or African-AmericanWhiteAsianNative Hawaiian or other Pacific Islander7. What is the highest grade or level of school that you have completed? Less than high school High school graduate or GED Some high school Some college or vocational school College graduate or higher 8. Are you limited in any way in any activities because of physical, mental, or emotional problems? YES NO 9. In general, would you say that your health is: Excellent Very Good Good Fair Poor 10. How fearful are you of falling? Not at all A little Somewhat A lot 11. 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)? Hold shift key and click to multi-select.Arthritis or other bone/joint diseaseBreathing/lung diseaseCancerDepressionDiabetesHeart disease/blood circulation problemHigh blood pressure/hypertensionGlaucoma/other chronic eye problemOsteoporosisParkinson's DiseaseOther Chronic Condition(s) (please list): 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.12. In the past 3 months, how many times have you fallen? If you fell in the past 3 months:a. how many of these falls caused an injury? (By injury we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.)b. where did the falls(s) occur? Indoors Outdoors Both indoors and outdoors c. what happened after you fell and had an injury? Please check all that apply. Use shift key and click to multi-select.Went to the Emergency RoomVisted my Primary Care PhysicianWas admitted to the hospitalDid not seek medical careHow sure are you that you can do the following activities?a) I can find a way to get up if I fall Very sure Sure Somewhat sure Not at all sure b) I can find a way to reduce falls Very sure Sure Somewhat sure Not at all sure c) I can protect myself if I fall Very sure Sure Somewhat sure Not at all sure d) I can increase my physical strength Very sure Sure Somewhat sure Not at all sure e) I can become more steady on my feet Very sure Sure Somewhat sure Not at all sure 14. 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 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? Vigorously active for at least 30 minutes, 3 times per week Moderately active at least 3 times per week Seldom active, preferring sedentary activities Thank you for completing the Tai Chi for Arthritis First Session Survey
