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ACL Falls Prevention Innovation Lab: Post Survey for Participants
Step
1
of
5
- Outcomes Measures: ADLs
20%
Comments
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Date
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Participant ID
Your Name
First
Last
Your Email
Outcome Measures : ADLs
ADLs: What is your level of independence with the following?
Bathing: The ability to wash oneself, including getting in and out of the shower or bathtub.
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Dressing: The ability to choose appropriate clothing and put them on and take them off.
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Toileting: The ability to use the toilet, including managing personal hygiene.
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Transferring: The ability to move from one position to another, such as transferring from a bed to a chair.
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Continence: The ability to control bowel and bladder functions.
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Feeding: The ability to feed oneself, including the physical act of eating
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Mobility: The ability to move around one's home.
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Outcomes Measures: IADLs
IADLs: What is your level of independence with the following?
Transportation and shopping: The ability to shop for clothing and other items required for daily life, attend events, and manage transportation, either via driving or by organizing other means of transport.
Not applicable
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Managing finances: The ability to pay bills and manage financial assets.
Not applicable
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Shopping and meal preparation: The ability to shop for groceries and prepare a meal.
Not applicable
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Housecleaning and home maintenance. Cleaning kitchens after eating, maintaining living areas reasonably clean and tidy, and keeping up with home maintenance.
Not applicable
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Managing communication with others: The ability to manage telephone and mail.
Not applicable
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Managing Medications: The ability to obtain medications and take them as directed.
Not applicable
Unable to do
Able to do with a lot of difficulty
Able to do with moderate difficulty
Able to do with a little difficulty
Able to do with no difficulty
Fear of Falling
How fearful are you of falling?
Not at all
A little
Somewhat
A lot
Since this program began, to what extent has your concern about falling interfered with your normal social activities with family, friends, neighbors or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
Falls Efficacy Scale
How confident are you today that you can do the following activities without falling? Score 1-10: 1 = not confident at all; 10 = very confident
Take a bath or shower
n/a
1
2
3
4
5
6
7
8
9
10
Reach into cabinets or closets
n/a
1
2
3
4
5
6
7
8
9
10
Walk around the house
n/a
1
2
3
4
5
6
7
8
9
10
Prepare meals not requiring carrying heavy or hot objects
n/a
1
2
3
4
5
6
7
8
9
10
Get in and out of bed
n/a
1
2
3
4
5
6
7
8
9
10
Answer the door or telephone
n/a
1
2
3
4
5
6
7
8
9
10
Get in and out of a chair
n/a
1
2
3
4
5
6
7
8
9
10
Getting dressed and undressed
n/a
1
2
3
4
5
6
7
8
9
10
Personal grooming (i.e. washing your face)
n/a
1
2
3
4
5
6
7
8
9
10
Getting on and off of the toilet
n/a
1
2
3
4
5
6
7
8
9
10
History of Falls
Since this program began, how many times have you fallen?
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.)
Self-Rated Health
In general, would you say your health is:
Poor
Fair
Good
Very good
Excellent
How much pain do you experience daily?
None
Slight
Moderate
Severe
Extreme
What best describes your activity level?
Seldom active (preferring sedentary activity such as watching TV)
Light-intensity activity (slow walk, cooking, light household chores)
Moderate-intensity activity at least 3 times per week (brisk, walking, raking the yard)
Vigorous-intensity activity at least 3 times per week (jogging, shoveling snow, fitness class)
How often do you feel lonely?
Never
Rarely
Sometimes
Often
Always
How often do you feel isolated from those around you?
Never
Rarely
Sometimes
Often
Always
How would you rate your mental health, which includes feeling of anxiety and/or depression, on most days in the past month?
Excellent
Very Good
Good
Fair
Poor
Do you use an assistive device such as a cane, walker, rollator, scooter, wheelchair, etc.?
Yes
No
If yes, please specify
Readiness for Taking Future Action
I feel more comfortable talking to my health care provider about my medications and other possible risks for falling.
n/a
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I feel more comfortable talking to my family and friends about falling.
n/a
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I feel more comfortable increasing my activity.
n/a
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I feel more satisfied with my life.
n/a
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I plan to continue to exercise.
n/a
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I have safety modifications in my home, such as installing grab bars or securing loose rugs.
n/a
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Program Satisfaction
Satisfaction with the program
Very dissatisfied
Dissatisfied
Okay
Satisfied
Very satisfied
Satisfaction with the location
Very dissatisfied
Dissatisfied
Okay
Satisfied
Very satisfied
Satisfaction with the length of each session
Very dissatisfied
Dissatisfied
Okay
Satisfied
Very satisfied
Satisfaction with the length of the program
Very dissatisfied
Dissatisfied
Okay
Satisfied
Very satisfied
Satisfaction with leader(s)
Very dissatisfied
Dissatisfied
Okay
Satisfied
Very satisfied
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