2007-02-27 Fall Prevention Phone Screening

Referral Number:

Participant Name:
Address:
Phone Number:

Independent Living
and

Mobility Program
Phone Screening
Assessment
Assessor – Print your name with credentials and the date that the interview was completed.
Name and credentials: ______________________________________________
Date of interview: __________________________________________________

Phone Screen draft 2007-02-27 JM

1

Introduction

Enter the time the
interview begins
(i.e. 2:53 PM).

Exact time:
:

am/pm

INITIAL CONTACT- Talking to insured

Hi, my name is _____ and I am calling on behalf of (Name of Insurance Company), your long-term care insurance company.
A few weeks ago, you agreed to participate in a national Program about Independent Living and Mobility that your LTC
insurance company is participating in. First, we want to thank you for your willingness to contribute to helping us understand
such an important issue. As part of the Program, we need to ask you some questions related to your general health history.
It will take about 20 minutes. Do you have time to do that now or would you like to schedule a time that is more convenient
for you?

INITIAL CONTACT - Talking to proxy

Hi, my name is _____ and I am calling on behalf of (Name of Insurance Company), (the insured’s name)’s long-term care
insurance company. A few weeks ago, you agreed to participate in a national Program about Independent Living and
Mobility that their LTC insurance company is participating in. First, we want to thank you for your willingness to contribute to
helping us understand such an important issue. As part of the Program, we need to ask you some questions related to (name
of insured)’s general health history. It will take about 20 minutes. Do you have time to do that now or would you like to
schedule a time that is more convenient for you?

FINAL CONTACT - Talking to insured

Hi, my name is _____ and I am calling on behalf of (Name of Insurance Company), your long-term care insurance company.
You have been participating in a national Program about Independent Living and Mobility for the past 24 months. As the last
telephone contact, we need to ask you the questions that we asked you at the very beginning of the Program. It will take
about 20 minutes. Do you have time to do that now or would you like to schedule a time that is more convenient for you?

FINAL CONTACT - Talking to proxy

Hi, my name is _____ and I am calling on behalf of (Name of Insurance Company), (the insured’s name)’s long-term care
insurance company. (the insured’s name) has been participating in a national Program about Independent Living and Mobility
for the past 24 months. As the last telephone contact, we need to ask you the questions that we asked at the very beginning
of the Program. It will take about 20 minutes. Do you have time to do that now or would you like to schedule a time that is
more convenient?

General Questions
1.

Are you having any difficulty understanding me? (If “Yes,” explain how you compensated below).................................................
Compensation:

2.

With whom do you live?

3.

4.

Alone
Spouse
Child(ren)
Grandchild(ren)
Parent
Sibling
Other (name/relationship: )______________________
Do you live in a private residence (Free standing home or apartment/condominium)? ...................................................................
If Yes, Is this part of an: Assisted Living Facility, Retirement Community or Elderly Housing? ......................... No Yes
Assisted Living Facility
Retirement Community
Elderly Housing
If Yes, indicate which:
If No, Do you live in:
Assisted Living Facility
Retirement Community
Nursing Home
Other, type:
At the present time would you say your health is:
Excellent
Good
Fair
Poor

Phone Screen draft 2007-02-27 JM

No

Yes

No

Yes

2

Healthcare Use
5.
6.
7.

Do you have a primary care doctor or other physician you see regularly or when you have a medical problem?...........................
How often do you usually see a doctor?
Monthly
~3 Mo
~6 Mo
Yearly
< Yearly
Rarely
In the past 2 years, have you had any surgery?..............................................................................................................................
If Yes, indicate number of times: _________
8. In the past 2 years, have you had any emergency room visits? ......................................................................................................
If Yes, indicate number of times: _________
9. In the past 2 years, have you had any hospital admissions?...........................................................................................................
If Yes, indicate number of times: _________
10. Do you receive personal care or assistance from any paid or unpaid caregivers?...........................................................................
Paid Caregiver(s)
Unpaid Caregiver(s)
Both Paid and Unpaid Caregiver(s)
If Yes, Identify:
Approximately how much money do you spend per month on these paid caregivers?
none
less than $100
$100-$250
$251-$500
$501-$1000
$1001 or more

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

11. In the past week or so, have you felt any…
a. Lower body muscle weakness or generalized fatigue?............................................................................................................

No

Yes

b. Pain in your back that affects your mobility or daily activities? ..............................................................................................

No

Yes

c. Loss of balance or unsteadiness when you walk or get up from a chair or bed?......................................................................

No

Yes

d. Dizziness or vertigo when you walk or get up from a chair or bed? ........................................................................................

No

Yes

12. Has a doctor ever told you that you have…
e. Arthritis, Bone or Joint problems affecting your mobility, legs, hips, knees, ankles or feet?...................................................

No

Yes

13. Do you have…
f. Paralysis of a leg or foot?........................................................................................................................................................

No

Yes

g. An amputation of a leg, foot or toe? ........................................................................................................................................

No

Yes

h. Impaired vision that cannot be corrected or are you blind?.....................................................................................................

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

Medical Conditions and Symptoms

Medications
14. Are you currently taking any prescription medications?..................................................................................................................
4-6
7-10
More than 10
If Yes, how many different medications do you take per day?.................. 1-3
15. Are you currently taking any non-prescription or over the counter medications?............................................................................
If Yes, how many different medications do you take per day?.................. 1-3
4-6
7-10
More than 10
16. Do you ever forget to take a medication or decide not to take one?................................................................................................
If Yes, About how often does this happen? 1-3 times/wk
4-6 times/wk
More than 6 times/wk
Why does this happen?
Forgets
Too expensive
Other: _______________
17. Do you take medication for any of the following conditions?
No Yes
No Yes
Stress ......................................................
Anxiety................................................
Memory loss or Memory Impairment ......
Depression ..........................................
18. Have you ever been treated for Depression? ..................................................................................................................................
If Yes, Are you currently being treated for depression? .............................................................................. No
Yes

Phone Screen draft 2007-02-27 JM

3

Falls History and Risks
19. How many times in the past 6 months have you had an episode of fainting, falling or dropping to the ground or lost your
balance, slipped or tripped over something that resulted in falling or dropping to the ground? ...................................................... _____ Times
a) If one (1) or more times, Did you get hurt? .............................................................................................. No
Yes
b) What has been your most serious injury or problem due to any fall? (check all that apply)
Never Injured
Bruises
Cuts Discomfort Fracture of leg
Fracture of wrist or arm
Fracture of back/vertebrae
Head injury
Other (specify)__________________
c) How long were you on the ground before you could get up? ________________
20. Do you ever limit your activities, for example, what you do or where you go because you are afraid of falling?........................... No Yes
21. Some things help to prevent falls. Do you currently do any of these?
a) Exercise program...................................................................................................................................... No
Yes
If “Yes” what type?
Yoga
Stretching
Tai Chi Walking Weights/Strengthening exercises
Swimming
Other (Specify) __________________
b) Regularly see your doctor......................................................................................................................... No
c) Participate in a community based fall prevention program ....................................................................... No
-------- previously we asked have you EVER participated in falls prevent. Program do we want to ask this?

Yes
Yes

Modified Geriatric Depression Scale (GDS IV)
1. Please choose the best answer for how you have felt over the past week.

Assessor, yes and no check boxes reverse depending on whether the question is posed as positive or negative.
1
2
3
4

Not
Question
Depressed
Are you basically satisfied with your life?............................................................... Yes
Have you dropped many of your activities and interests?...................................... No
Are you afraid that something bad is going to happen to you? .............................. No
Do you feel happy most of the time?....................................................................... Yes

Depressed
No
Yes
Yes
No

Total number of Depressed answers:

Phone Screen draft 2007-02-27 JM

4

TICS
2. Next, I am gong to ask you some questions to test your memory. Some of these are likely to be easy for you, but some
may be difficult. Please bear with me and try to answer all the questions as best you can. If you can’t answer a
question, don’t worry, just try your best. If you have a television or radio on, please turn it off so that you are not
distracted for this part of the interview. Are you ready? ...............................................................................................................
If No, why not? Refused to complete
Other, explain_________________________________
Question
Please tell me your full name
What is today’s date?

Where are you right now?

Answer

No

Correct Incorrect

First:
Last:
Month:
Day:
Year:
Day of week:
Season:
Number:
Street:
City:
State:
Zip Code:

Please count backwards from 20 to 1
1st try:
If error: Please count backwards from 20 to 1
2nd try:
I am going to read to you a list of 10 words. Please listen carefully and try to memorize them. When I am done, tell me as
many of the words as you can in any order . Ready? OK, the words are…Assessor – say each word slowly and use
clear enunciation. Pause for 1 second after each word is said..

Cabin
Check if recalled:
Pipe
Check if recalled:
Elephant
Check if recalled:
Chest
Check if recalled:
Silk
Check if recalled:
Theater
Check if recalled:
Watch
Check if recalled:
Whip
Check if recalled:
Pillow
Check if recalled:
Giant
Check if recalled:
I would like you to take the number 100 and subtract 7
Answer:
Now keep subtracting 7 from the answer Until I tell you to stop Answer:
Answer:
Answer:
Answer:

What do people usually use to cut paper?
Answer:
How many things are in a dozen?
Answer:
What do you call the prickly green plant that lives in the desert? Answer:
What animal does wool come from?
Answer:
Please repeat this after me “No ifs, ands or buts”
Answer:
Now please repeat this after me “Methodist Episcopal”
Answer:
With the tip of your finger, tap 5 times into the part of Taps are heard:
the phone you speak into.
Total number of taps = 5:
I am going to say a word and I want you to give me its opposite. For Example, if I said “hot” you would say “cold”
What is the opposite of west?
Answer:
Total correct:_________
Phone Screen draft 2007-02-27 JM

5

Yes

Ambulation
3.
4.
5.
6.
7.
8.
9.

Do you have difficulty walking without help from another person?.................................................................................................
Do you have difficulty getting in and/or out of your home?.............................................................................................................
Do you have difficulty walking from one room to another inside your home? ................................................................................
Do you have difficulty walking inside your home without the use of furniture or other items to steady yourself? .........................
Do you have any electrical cords, furniture or clutter that cross walkways, hallways or pathways in your home? .........................
Do you have any slippery throw rugs (scatter rugs) in your home that are not fastened to the floor? ............................................
Do you have difficulty getting around outside your home within walking distance including negotiating uneven surfaces? ...........

No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

GETTING IN AND OUT OF A BED OR CHAIR?................................................................................................................................
i) Getting in and out of a chair without using your hands to push off? ....................................................................................
ii) Getting up from the floor without help from another person? ............................................................................................
j) DRESSING AND UNDRESSING YOURSELF?....................................................................................................................................
k) BATHING YOURSELF? ................................................................................................................................................................
i) Getting in and out of your bathtub or shower? ....................................................................................................................
l) FEEDING YOURSELF? .................................................................................................................................................................
m) TOILETING? ..............................................................................................................................................................................
i) Getting on or off of your toilet? ...........................................................................................................................................
n) MAINTAINING CONTINENCE OR CARING FOR PERSONAL HYGIENE AFTER INCONTINENCE OCCURS?...............................................

No
No
No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

11. Do you have non-slip surfaces/mats inside and outside your tub/shower? .....................................................................................

No

Yes

IADL/ADL Evaluation
10. Do you have difficulty doing any of the following activities without help from another person?
a) TAKING YOUR MEDICATIONS: (opening bottles, measuring correct doses, taking them at the correct time)? ............................
b) USING THE TELEPHONE: (answering the phone. looking up numbers and dialing)?....................................................................
c) MANAGING YOUR FINANCES: (paying bills, writing checks, balancing your checkbook)? ...........................................................
d) DOING YOUR HOUSEWORK: (making beds, dusting, vacuuming, cleaning the floors, the kitchen and bathroom)?.....................
e) DOING YOUR LAUNDRY: (transferring clothes to/from washer/dryer, and putting clean items away)?.....................................
f) SHOPPING FOR GROCERIES: (getting to store, obtaining, paying for, carrying home and putting away all needed items)? .......
g) TRANSPORTING YOURSELF: (driving or arranging a ride, getting to/from and in/out of the vehicle by yourself)? .....................
h) PREPARING YOUR MEALS: (planning, preparing and serving complete, well-balanced meals)? .................................................
i)

Phone Screen draft 2007-02-27 JM

6

Medical Equipment
12. In the last week or so, have you used any of the following medical equipment or devices? (if “Yes,” explain below)
No

Yes

13. Have you made any modifications to the outside or inside of your home to improve its safety? ....................................................
If Yes, what type of modification(s):
Why?
Approximately how much of your own money did you spend to improve your home’s safety?
I did not spend my own money
less than $50
$50-$100
$101-$150
$151-$200
$201-$250
$251-$300
other amount__________

No

Yes

No

Yes

No
No
No
No
No
No
No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Wheelchair ...................
Walker .........................
Cane.............................
Crutches .......................
Prosthesis/Leg Braces ..

No

Yes

Electric Chair Lift ......................
Electric Stair Lift .......................
Electric Cart or Scooter .............
Raised Toilet Seat.....................
Toilet Safety Frame/grab bar ...

No

Yes

Bedside Commode....................
Urinary Catheter ......................
Oxygen Equipment...................
Grab Bars in Tub or Shower......
Other:
.....

If “Yes,” Why do you use the equipment?
In the home
Outside
Where do you use this equipment?
Approximately how much of your own money did you spend on this equipment?
I did not spend my own money
less than $50
$50-$100
$101-$150
$151-$200
$201-$250
$251-$300
don’t know/came with house
Other amount__________

Height and Weight
14. What is your height? _____ ft _____in
15. What is your weight? ____________lbs

Visual Acuity
16. Do you have glasses or contact lenses? ..........................................................................................................................................
Most of the time
Sometimes
For special reasons (such as driving or reading)
Do you wear them
Never
17. Have you had an eye exam or your vision checked by a doctor or optometrist in the last five years? ...........................................
18. Can you see well enough (with glasses, if needed) to read the newspaper?....................................................................................
19. Can you see well enough (with glasses, if needed) to watch television? .........................................................................................
20. Can you see well enough (with glasses, if needed) to read writing on television? ..........................................................................
21. Can you see well enough (with glasses, if needed) to read medicine bottles? ................................................................................
22. Can you see well enough (with glasses, if needed) to walk downstairs in daylight? .......................................................................
23. Can you see well enough (with glasses, if needed) to walk downstairs in dim light? ......................................................................
24. Can you see well enough (with glasses, if needed) to recognize someone across the room? ..........................................................

Phone Screen draft 2007-02-27 JM

7

Physical Activity Scale for the Elderly (PASE)
Now I am going to ask you some questions about your daily activities. Please let me know if in the past 7 days you
have done any of these activities.
Household Activity
During the past 7 days…
25. Have you done any light housework, such as dusting or washing dishes?.......................................................................................
26. Have you done any heavy housework/chores, such as vacuuming, scrubbing floors, washing windows, or carrying wood?...........

No
No

Yes
Yes

Did you engage in any of the following activities?
Home Repairs like painting, wallpapering, electrical work etc… ...................................................................................................
Lawn work or yard care including snow or leaf removal, wood chopping, etc… ............................................................................
Outdoor Gardening..........................................................................................................................................................................
Caring for another person such as children, dependent spouse or another adult?...........................................................................

No
No
No
No

Yes
Yes
Yes
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

27.
28.
29.
30.

Work Related Activity
31. During the past 7 days did you work for pay or as a volunteer? (If “Yes,” explain below) .............................................................
A. How many hours did
you work in the past B. Which best describes the activities that are required at your work
7 days?
1-8 hours
Mainly sitting with slight arm movements
(Office worker, watchmaker, assembly line worker, bus driver)

9-20 hours

Sitting or Standing with some walking

21-30 hours

Walking with some handling of material generally weighing less than 50 lbs.

31-40 hours

Walking and heavy manual work often handling materials over 50 lbs.

(Cashier, general office worker, light tool and machinery worker)

(Mailman, waiter/waitress, construction or heavy tool/machinery worker)
(Lumberjack, stone mason, farm or general laborer)

Leisure-Time Activity
Over the past 7 days, did you…
32. Take a walk outside your home or yard for any reason? (e.g.: for fun exercise, walking to work, walking the dog, etc) ...............
If Yes, How many days in the past week did you walk? __________
On Average, how many minutes per day did you spend walking? ________
33. Engage in light sport or recreational activities such as bowling, golf with a cart, shuffleboard, fishing from boat or pier or
other similar activities?....................................................................................................................................................................
If Yes, How many days in the past week did you participate in these activities? __________
On Average, how many minutes per day did you spend doing these activities? ________
34. Engage in moderate sport and recreational activities such as doubles tennis, ballroom dancing, hunting, ice skating, golf
without a cart, softball or other similar activities?...........................................................................................................................
If Yes, How many days in the past week did you participate in these activities? __________
On Average, how many minutes per day did you spend doing these activities? ________
35. Engage in strenuous sport and recreational activities such as jogging, swimming, cycling, singles tennis, aerobic dance,
skiing (down hill or cross country) or other similar activities?..........................................................................................................
If Yes, How many days in the past week did you participate in these activities? __________
On Average, how many minutes per day did you spend doing these activities? ________
36. Do any exercise specifically to increase muscle strength/endurance such as lifting weights, doing push-ups,. Sit-ups etc? ............
If Yes, How many days in the past week did you participate in these activities? __________
On Average, how many minutes per day did you spend doing these activities? ________
37. Do any exercise specifically to increase balance or flexibility (stretching) such as yoga, Tai Chi, etc?............................................
If Yes, How many days in the past week did you participate in these activities? __________
On Average, how many minutes per day did you spend doing these activities? ________

Phone Screen draft 2007-02-27 JM

8

Demographics
38.
39.
40.
41.

What is your marital status?
Married
Widowed
Divorced
Never Married
What is your date of birth?_____/_____/______
What is your gender
Male
Female
What is your highest level of education?
Less than high school graduate
High School graduate
Some college or Associate’s Degree College graduate
Graduate Degree
42. Are you of Hispanic or Latino origin?
Yes
No
43. Which of the following describes your race? You may choose more than one.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or
other Pacific Islander
White
Other race (do not read)___________________
Refused to disclose/Uncertain (do not read)
44. To get a picture of people’s financial situation, we need to know your total household income from all sources, before taxes in (YEAR). This
includes social security, retirement income, job earnings, dividends, public assistance, help from relatives and any other source of income you may
$50,000 or greater?
have. Would you say that your household income was .................................................................. Less than $50,000
Was it:

If less than $50,000

If greater than or equal to $50,000

ˆ
ˆ
ˆ
ˆ
ˆ

ˆ
ˆ
ˆ
ˆ
ˆ
ˆ

Under $25,000
Under $35,000 ($25,000-$34,999)
Under $50,000 ($35,000-$49,999)
Don’t know
Refused

Under $75,000 ($50,000-$74,999)
Under $100,000 ($75,000-$99,999)
Under $150,000 ($100,000-$149,999)
$150,000 and over
Don’t know
Refused

Enter the time the
interview ends
(i.e. 3:24 PM).

Phone Screen draft 2007-02-27 JM

Exact time:
:

am/pm

9

Wrap up
INITIAL CONTACT- Talking to insured

Thank you for taking the time to answer my questions, we really appreciate your contribution. In the near future, you will
receive an Exercise Progress Chart and a Falls Journal in which you can record any falls or near falls that may occur. You
may also receive another telephone call shortly to set up an interview in your home, or we will be in touch with you couple of
months to see how you are doing.

INITIAL CONTACT- Talking to proxy

Thank you for taking the time to answer my questions, we really appreciate your contribution. In the near future, (name of
insured) will receive an Exercise Progress Chart and a Falls Journal in which you can record any falls or near falls that may
occur. You may also receive another telephone call shortly to set up an interview in (name of insured’s) home, or we will be
in touch with you in a couple of months to see how (name of insured) is doing.

FINAL CONTACT- Talking to insured or proxy

Thank you for taking the time to answer my questions, we really appreciate your contribution to this important research
Program. I want to thank you once again for participating in the Independent Living and Mobility Program your contributions
may result in safer practices and home environments for older adults.

Clinical Summary: Provide an answer for each question
45. Do you believe that the participant would have difficulty performing any of his/her IADL’s and ADL’s without assistance
from another person due to an impairment?....................................................................................................................................
If Yes, due to cognitive impairment ............................................................................................. No
Yes

No

Yes

46. Did the participant appear apathetic or require prompting or motivating to answer questions or complete the interview?............
If Yes, explain:

No

Yes

47. Was there evidence of sad or depressed mood or flattened affect? ................................................................................................
If Yes, explain:

No

Yes

48. Did the participant have difficulty following directions? ..................................................................................................................
If Yes, explain:

No

Yes

49. Was the participant unable to answer any questions or did the participant refuse to answer any of the questions? ......................
If Yes, explain:

No

Yes

If Yes, due to physical impairment.............................................................................................. No
Yes
If Yes to either, explain ________________________________________________

Assessor signature:

Phone Screen draft 2007-02-27 JM

Date of interview:

10