Participant Form

[Program Name] Participant Information Form
Public Burden Statement:
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 averages and estimate of .10 hours per response, including time for gathering, maintaining the
data, completing, and reviewing the collection of information. The obligation to respond to this collection is voluntary.

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?
2. How old are you today?

4. Are

No

years
Yes

3. Do you live

Yes

Male

No

alone?

Female

you:

Prefer Not to Say

5. Are you of Hispanic, Latino, or Spanish

Yes

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

origin?

No

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)?
YES

NO

YES

Alzheimer’s Disease or other
dementia
Anxiety Disorder
Arthritis/Rheumatic Disease
Asthma/Emphysema/Other
Chronic Breathing or Lung Proble
Cancer or Cancer Survivor

Hypertension (High Blood
Pressure)
Kidney Disease
Obesity
Osteoporosis (Low Bone
Density)
Parkinson’s Disease

Chronic Pain

Schizophrenia or Other
Psychotic Disorder

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m

NO

Depression
Diabetes (High Blood Sugar)

Stroke
Traumatic Brain Injury

Heart Disease

Urinary Incontinence

High Cholesterol

Other Chronic Condition

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

Fair

10. How often do you feel lonely or isolated from those around you?
Never
Rarely
Sometimes
Often

Poor

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.
None
______times
11. Since this program began, how many times have you fallen?
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.)
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

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 Somewhat Neutral
Sure
sure
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
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Very Sure

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

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