APPENDIX G
QUARTERLY TELEPHONE INSTRUMENT
R
Participant Name:
Address:
Phone Number:
Independent Living and
Mobility Program
Quarterly Follow-up
Assessor – Print your name with credentials and the date that the interview was completed.
Name and credentials:
Date of interview:
My name is ______________, and I am calling in regard to the Independent Living and Mobility Program. I am calling to get updated information regarding your current Exercise Routine and to see how you have been doing since we last contacted you. The interview will take approximately 5-15 minutes. Is this a good time?
If not, schedule a time to call the participant back to complete phone screen.
Since we last talked, have you seen your primary care doctor? No Yes
Since we last talked, have you had any new symptoms or been diagnosed with any new conditions? No Yes
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Condition |
Date of Diagnosis/ 1st Symptom |
Date of most recent Symptom |
Is Condition treated by a doctor? |
Is Condition Controlled/ Stable? |
Treatment |
1 |
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No Yes |
No Yes |
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2 |
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No Yes |
No Yes |
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3 |
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No Yes |
No Yes |
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Since we last talked, have you started any new medications? No Yes
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Medication Name |
Dosage |
Frequency |
If PRN, indicate how often used? |
Reason for taking |
1 |
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2 |
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3 |
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Since we last talked, have you discontinued any medications? No Yes
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Medication Name |
Reason stopped taking |
1 |
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2 |
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3 |
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Since we last talked, have you had any changes in any of your medication dosages or how often you take them? No Yes
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Medication Name |
Dosage |
Frequency |
If PRN, indicate how often used? |
1 |
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2 |
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3 |
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Since we last talked, have you had any new treatments prescribed or recommended? No Yes
If Yes, What type of treatment? Physical Therapy Occupational Therapy
Other:
Why?
Since we last talked, have you had any Hospital Admissions, Emergency Room visits or Surgery? No Yes
If Yes, indicate number of times: _________times and supply details below:
|
Reason for Hospital Admission/ Emergency Room visit/ Surgery |
Date (month/year) |
Type of Surgery &/or Treatment received |
Current Status |
1 |
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2 |
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3 |
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Since we last talked, have you changed your primary care doctor? No Yes
If Yes, Why?
New Physician’s name: Phone number:
City: State Street address:
Specialty:
The next questions refer to your exercise routine.
Have you been filling in the Exercise Progress Chart on a daily or weekly basis? No Yes
If Yes, you may want to refer to it as you answer the next few questions
In the past 7 days have you participated in any exercise? No Yes
If Yes, How many days (in the past week)? 1 day 2 days 3 days 4 days
5 days 6 days 7 days
How many hours per day?
<1 hr but more than 30 min 1 hour >1 hr but less than 2 hr 2 hours
>2 hr but less than 3 hr 3 hours >3 hours Other:__________
What type of exercise?
Endurance= increase breathing/heart rate (brisk walk, stairs, swim, aerobics, jog, cycle, tennis, dance, shovel, ski, hike, rake/row lawn, mop/scrub floor)
Strength= build muscles (weights, chair stands, arm/leg raises, hip/knee/shoulder flexion/extension, sit-ups, push-ups)
Balance= improve/maintain balance (heel-to-toe walk, stand on one foot, strength exercises using one hand/one finger for holding on or not holding on)
Flexibility= stretching to improve freedom of movement (arm, shoulder, wrist, leg, ankle, hip and neck stretching)
Has this been your typical routine over the past 3 months? No Yes
If No, How often do you usually exercise? 1 day/wk 2 days/wk 3 days/wk 4 days/wk
5 days/wk 6 days/wk 7 days/wk
How many hours per day?
<1 hr but more than 30 min 1 hour >1 hr but less than 2 hr 2 hours
>2 hr but less than 3 hr 3 hours >3 hours Other:__________
What type of exercise?
Endurance= increase breathing/heart rate (brisk walk, stairs, swim, aerobics, jog, cycle, tennis, dance, shovel, ski, hike, rake/row lawn, mop/scrub floor)
Strength= build muscles (weights, chair stands, arm/leg raises, hip/knee/shoulder flexion/extension, sit-ups, push-ups)
Balance= improve/maintain balance (heel-to-toe walk, stand on one foot, strength exercises using one hand/one finger for holding on or not holding on)
Flexibility= stretching to improve freedom of movement (arm, shoulder, wrist, leg, ankle, hip and neck stretching)
Why have you not been following your typical exercise routine?
Would you like for us to mail you some more Weekly Schedules for your Exercise Progress Chart? No Yes
The next questions refer to any fall that you may have experienced in since we last contacted you.
Since our last call, have you had one or more episodes of fainting, falling or dropping to the ground, passing out or have you lost your balance or tripped over something that resulted in falling or dropping to the ground? No Yes
If Yes, How many times did this happen?
Do you fill out the Fall Journal whenever you have a fall? No Yes
If Yes, you may want to refer to it as you answer the next few questions
What time of day did you fall? Day Eve
Morn/Day 5:01AM-9:00AM 9:01AM-12:00PM 12:01PM-4:00PM
Eve/Noc 5:01PM-7:00PM 7:01PM-10:00AM 10:01AM-5:00AM
Did you sustain any injuries? No Yes
Did you require Medical Attention? No Yes
Doctor Visit Hospital Admission Emergency Room Visit
What were you doing when you fell?
Were you at home when you fell? No Yes
If Yes, Where? Bathroom Kitchen Stairs Entryway Other:
If No, Where? Store/Business Parking Lot/Street Relative/Friend House
Dr. Office Walkway/Pathway Other
What was the cause of your fall? Tripped Slipped Dizziness Seizure
Loss of Balance Fainted/Blacked out Other:
Were any of the following conditions present when you fell?
Ground conditions |
|
Behaviors For each Yes*, answer additional *question* below |
|
Wet Ground |
No Yes |
Wearing shoes that did not fit properly |
No Yes* |
Icy/snowy Ground |
No Yes |
Wearing clothes that did not fit properly |
No Yes* |
Uneven Ground |
No Yes |
Not using necessary visual aid/glasses |
No Yes* |
Stepping up onto/down from a Curb |
No Yes |
Not using necessary equipment |
No Yes* |
Climbing up/going down stairs |
No Yes |
(cane, walker, shower seat, grab bars) |
|
Object in walkway/path |
No Yes |
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*Have you changed this behavior to prevent future falls? No Yes
Have you been anxious, worried or afraid you might fall? No Yes
Do you ever limit your activities, for example, what you do or where you go because you are afraid of falling? No Yes
If Yes, Explain:
Since we last talked, have you made any changes to your home or to your behavior to prevent future falls? No Yes
If Yes, which activities and why?
How often? All of the time Some of the time Rarely Doesn’t know
Have you spent any of your own money to implement any of these changes? No Yes
If Yes, how much? $_________
Were you reimbursed for any of these expenses? No Yes
Since we last talked, are you less fearful of falling? No Yes
If Yes, Explain why:
Thank you again for participating in the Falls Preventions study. We will be calling you in another three months to see how you are doing.
Is there a best day of the week and/or time of day for us to call you so that the interview will be convenient for you? No Yes
If Yes, Day of week? Sun Mon Tues Wed Thur Fri Sat
Time of day? 8am-12pm 12pm-4pm 4pm-8pm Other:__________
Eastern Central Mountain Pacific
The Effect of Reducing Falls on Long Term Care Expenses – Literature Review
File Type | application/msword |
File Title | APPENDIX A |
Author | LifePlans |
Last Modified By | DHHS |
File Modified | 2006-08-31 |
File Created | 2006-08-31 |