TCA/FP Last Session Survey TCA/FP Last 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. In general, would you say that your health is: Excellent 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? (Please use numbers -- 0, 1, 2, 3, etc.)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.) b. where did the fall(s) occur? 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? Not at all A little Somewhat A lot 4. Please check the box that tells us how sure you are that you can do the following activities. How sure are you that: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 5. 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 6. Please tell us your thoughts about this program. Check one box for each question. As a result of this program:a. I feel more comfortable talking to my health care provider about my medications and other possible risks for falling Strongly Agree Agree Disagree Strongly Disagree b. I feel more comfortable talking to my family and friends about falling Strongly Agree Agree Disagree Strongly Disagree c. I feel more comfortable increasing my activity Strongly Agree Agree Disagree Strongly Disagree d. I feel more satisfied with my life Strongly Agree Agree Disagree Strongly Disagree e. I would recommend this program to a friend or relative Strongly Agree Agree Disagree Strongly Disagree 7. Since this program began, what have you done to reduce your chance of a fall? Check all that apply. Talked to a family member or friend about how I can reduce my risk of falling Talked to a health care provider about how I can reduce my risk of falling Had my vision checked Had my medications reviewed by a health care provider or pharmacist Participated in another fall prevention program in my community 8. 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 9. 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
