Participant Information Form

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) 

_ __ /__ __/ __ __ 

1. Did your doctor, nurse, physical therapist or other health care provider suggest that 

you take this program? 

O Yes O No

2. How old are you today? years

3. Do you live alone? O Yes O No

4. Are you: O Male or O Female?

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

6. What is your race? Check all that apply. O American Indian or Alaska Native 

O Asian 

O Black or African American

O Native Hawaiian or other Pacific Islander

O White

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

O Less than high school

O Some high school

 O High school graduate or GED 

O Some college or vocational school

O College graduate or higher

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)? Check Yes or No.

Arthritis or other 

bone/joint disease Yes No

Breathing/lung disease  Yes  No

Cancer  Yes  No

Depression  Yes  No

Diabetes  Yes  No

Heart disease or blood 

circulation problem Yes  No

High blood 

pressure/hypertension Yes No

Glaucoma/other chronic eye 

problem Yes No

Osteoporosis Yes No

Parkinson’s Disease Yes No

Other Chronic Condition(s)

(specify):

_________________

____

________________

_____________

 

9. Are you limited in any way in any activities because of physical, mental, or 

 emotional problems? O Yes O No

 Please turn this paper over and fill out the other side. 
Extremely Quite a bit Moderately Slightly Not at all 

Not at all A little Somewhat A lot 

 Excellent Very good Good Fair Poor

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

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? O none O times 

If you fell in the past 3 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. 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

Visited my Primary Care Physician 

Was admitted to the hospital 

Did not seek medical care

12. How fearful are you of falling?

13. Please mark the circle that tells us how sure you are that you can do

the following activities.

How sure are you that: 

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?

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?

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

O Moderately active at least 3 times per week

 O Seldom active, preferring sedentary activities

Very Sure Sure Somewhat sure Not at all sure

a. I can find a way to get up if I fall O O O O 

b. I can find a way to reduce falls O O O O 

c. 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