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[Program Name] Participant Information Form

Admin Use Only: Participant I.D.: The facilitator or program staff should complete this part of the form and mark the sequential 

number of the participant to the name on the attendance form. 

State abbreviation: __ __ (e.g., NY, VA, etc.) 

First four letters of the site name: __ __ __ __ 

Start date of program: __ __ / __ __ / __ __ (e.g., 12/01/19) 

Participant number: __ __ (e.g., 01, 02, 03, etc.) 

1. Did your doctor or other health care provider suggest that you attend this program? 

 Yes  No

2. How old are you today? years

3. Do you live alone?  Yes  No

4. Are you:  Male  Female  Prefer not to say

5. Are you of Hispanic, Latino, or Spanish origin?  Yes  No

6. What is your race? Check all that apply.

 American Indian or Alaska Native

 Asian 

 Black or African American

 Native Hawaiian or other Pacific Islander 

 White

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

 Some elementary, middle, or high school

 High school graduate or GED

 Some college or technical school 

 College (4 years or more)

8. 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)? 

Alzheimer’s Disease or other dementia  Yes  No

Anxiety Disorder  Yes  No

Arthritis/Rheumatic Disease  Yes  No

Asthma/Emphysema/Other Chronic Breathing or Lung Problem  Yes  No

Cancer or Cancer Survivor  Yes  No

Chronic Pain  Yes  No
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Depression  Yes  No

Diabetes (High Blood Sugar)  Yes  No

Heart Disease  Yes  No

High Cholesterol  Yes  No

Hypertension (High Blood Pressure)  Yes  No

Kidney Disease  Yes  No

Obesity  Yes  No

Osteoporosis (Low Bone Density)  Yes  No

Parkinson’s Disease  Yes  No

Schizophrenia or Other Psychotic Disorder  Yes  No

Stroke  Yes  No

Traumatic Brain Injury  Yes  No

Urinary Incontinence  Yes  No

Other Chronic Condition  Yes  No

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

 Excellent  Very Good  Good  Fair  Poor 

10. How often do you feel lonely or isolated from those around you?

 Never  Rarely  Sometimes  Often  Always

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.

11. In the past 3 months, how many times have you fallen?  None ____times

If you fell in the past three months:

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. Did you tell anyone, such as a family member, friend, or healthcare provider about this fall, 

whether or not it resulted in an injury?

 Yes  No

c. what happened after you fell? (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

12. How fearful are you of falling? 

 Not at all  A little  Somewhat  A lot
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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?

 Not at all  Slightly  Moderately  Quite a bit  Extremely

14. Please use an X to tell us how sure you are that you can do the following activities. 

Not at all sure Somewhat sure Neutral Sure Very 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 increase my flexibility

d. I can increase my physical strength

e. I can become more steady on my feet

15. What best describes your activity level? 

 Vigorously active for at least 30 min, 3 times per week

 Moderately active at least 3 times per week

 Seldom active, preferring sedentary activities

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB 

control number (OMB 0985-0039). Public reporting burden for this collection of information is estimated to average 6 minutes per response, including time for 

gathering and maintaining the data needed and completing and reviewing the collection of information. The obligation to respond to this collection is required to 

retain or maintain benefits under the statutory authority of the Older Americans Act and Patient Protection and Affordable Care Act. OMB Control No. 0985-0039 

Exp. Date 04/30/2024