Form 0920-19ARD Baseline Survey

Form Approved OMB No: xxxx-xxxx

Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 15 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn:  PRA (xxxx-xxxx).

INTRO_1. This survey is for [FILL NAME]. Please confirm that you are this person.

01 I am this person [continue to intro_2]

02 I am NOT this person [continue to SCREEN_EXIT]

SCREEN_EXIT

This survey can only be completed by [FILL NAME]. Thank you. [EXIT SURVEY]

INTRO_2. Welcome to the Patient Falls Survey. We appreciate your help with this important study. Your participation is voluntary. You can refuse to answer a question or stop the survey at any time, and all information you provide is confidential, and will only be used for the purposes of this study.

Q1_INTRO. For purposes of this survey, you will be asked a series of questions about your health with a particular focus on falls. A fall is being defined as an event that resulted in a person unintentionally coming to rest on the ground, floor, or other lower level. Please keep this definition in mind as you complete the survey.

Q1. In the past 12 months, how many times have you fallen?

_____ Number of falls

If 0, go to Q3. Else go to Q2.

Q2. 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 injury

Recently you visited your Emory provider and participated in a falls risk screening. Our records indicate that visit took place on XX/XX/XXXX. Please answer the following questions, thinking about your life in the 12 months before that visit.

Q3. In general, would you say that your health was:

1 Excellent	2 Very Good	3 Good	4 Fair	5 Poor	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q4. In the 12 months before the Emory visit: On a scale of 1 to 5, where 1 means “not at all afraid” and 5 means “very afraid,” how afraid were you of falling?

1 Not at all Afraid	2	3	4	5 Very Afraid	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q5. In the 12 months before the Emory visit: On a scale of 1 to 5, where 1 means "not at all important" and 5 means "most important," how important was falling compared with your other health concerns?

1 Not at all Important	2	3	4	5 Most Important	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q6. In the 12 months before the Emory visit: On a scale from 1 to 5, where 1 means "not at all likely" and 5 means "very likely," how likely were you to fall?

1 Not at all Likely	2	3	4	5 Very Likely	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q7. In the 12 months before the Emory visit: On a scale from 1 to 5, where 1 means "not at all likely" and 5 means "very likely," if you fell, how likely is it that you would be hurt?

1 Not at all Likely	2	3	4	5 Very Likely	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q8. In the 12 months before the Emory visit: Think about your level of physical activity. Compared to other people your own age, do you think you were:

1 Much Less Active	2 Less Active	3 About as Active	4 More Active	5 Much More Active	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q9. In the 12 months before the Emory visit: Now thinking about your friends, compared to other people their own age, do you think your friends were:

1 Much Less Active	2 Less Active	3 About as Active	4 More Active	5 Much More Active	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

On a scale of 1 to 5, where 1 means “Strongly Disagree” and 5 means “Strongly Agree,” please indicate your agreement with the following statements, thinking about your life in the 12 months before that visit:	1 Strongly Disagree	2 Disagree	3 Neither Agree nor Disagree	4 Agree	5 Strongly Agree	77 Don’t Know	99 Prefer not to Answer
Q10. I would be embarrassed if my friends knew I fell.	□	□	□	□	□	□	□
Q11. My friends and I talked about the risk of falling.	□	□	□	□	□	□	□
Q12. My friends were worried about falling.	□	□	□	□	□	□	□
Q13. Older people fall and there is nothing that can be done about it.	□	□	□	□	□	□	□
Q14. There are things I can do to reduce my risk of falling.	□	□	□	□	□	□	□

In the 12 months before the Emory visit:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q15. Did you have your vision tested?	□	□	□	□
Q16. Did you visit a foot doctor?	□	□	□	□
Q17. Did you see a mental health professional, such as a therapist, counselor, or psychiatrist?	□	□	□	□
Q18. Did you make any changes to your home to help prevent falls?	□	□	□	□
Q19. Did you have any physical or occupational therapy?	□	□	□	□
Q20. Did you have a balance disorder or other condition that caused you to feel unsteady or dizzy?	□	□	□	□
Q21. Did you speak with a health care provider about preventing falls?	□	□	□	□

	1 Tai Chi	2 Matter of Balance	3 Other Exercise	77 Don’t know	99 Prefer not to Answer
Q22. In the 12 months before the Emory visit, did you participate in any of the following exercise programs: Tai Chi, Matter of Balance, or some other exercise?	□	□	□	□	□

In the 12 months before the Emory visit, did you take:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q23. Medicine prescribed for you to help you sleep such as zolpidem (Ambien), zaleplon (Sonata), or eszopiclone (Lunesta)?	□	□	□	□
Q24. Over-the-counter medicine to help you sleep such as diphenhydramine (Benedryl, ZZZQuil, Tylenol PM) or doxylamine (Unisom)?	□	□	□	□
Q25a. Opioid medicine prescribed for you to help with pain? These might include tramadol (Ultram), oxycodone (Roxicodone, Percocet, Oxycontin), hydrocodone (Lortab, Vicodin), morphine (MsContin), hydromorphone (Dilaudid), or fentanyl (Duragesic).	□	□	□	□
Q25b. Non-opioid medicine prescribed for you to help with pain, such as ibuprofen (Motrin), naproxen (Naprosyn), or diclofenac (Voltaren)?	□	□	□	□
Q26. Over the counter medicine to help with pain such as ibuprofen (Motrin, Advil), acetaminophen (Tylenol) or naproxen (Aleve)?	□	□	□	□
Q27. Medicine prescribed for you to help your mood or for sadness, such as sertraline (Zoloft), citalopram (Celexa), or duloxetine (Cymbalta)?	□	□	□	□
Q28. Medicine prescribed for you to help with anxiety or nervousness, such as alprazolam (Xanax), lorazepam (Ativan), or diazepam (Valium)?	□	□	□	□
Q29. Medicine prescribed for you to help with mood stability, such as risperidone (Risperdal), aripiprazole (Abilify), or quetiapine (Seroquel)?	□	□	□	□
Q30. Vitamin D or a multivitamin?	□	□	□	□

Q31. How many prescription medications do you take regularly?

______ number of medications

Q32. In the last three months, on average, how many days per week did you have any alcohol to drink?

0 Zero or Less than One Day per Week	1 Day per Week	2 Days per Week	3 or More Days per Week	77 Don’t know	99 Prefer not to Answer
□	□	□	□	□	□

Q33. Did you use marijuana in the last 30 days?

1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
□	□	□	□

Q34. Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

0	1	2	3	4	5	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□	□

Q35. What is your ethnicity?

01 Hispanic or Latino

02 Not Hispanic or Latino

Q36. What is your race? Select one or more.

01 American Indian or Alaska Native

02 Asian

03 Black or African American

04 Native Hawaiian or Other Pacific Islander

05 White

TOKEN. Those are all the questions. Thank you for taking the time to participate today. You will be contacted again in approximately three months to answer follow-up questions about your experience with falls. Please remember to track your survey participation and falls in your falls tracking log, which was provided to you by your medical provider. If you don’t have the falls tracking log, you can use any calendar. Tracking this information will make it easier to answer the questions in the follow-up survey.

As a token of our appreciation, we will send you postage stamps valued at $3.

Please confirm that your mailing address is:

[FILL NAME AND MAILING ADDRESS FROM SAMPLE FILE]

01 My address is correct. [Go to Q35]

02 My address is NOT correct. [go to TOKENADD]

03 Please do NOT send stamps. [Go to Q35]

TOKENADD.

Please enter your mailing address.

FIRST AND LAST NAME _____________

STREET ADDRESS __________________________

CITY ____________________

STATE ________________________

ZIP CODE _________________________

[GO TO Q35]

Q35. How would you like to be contacted to complete the follow-up survey?

1. I prefer to complete the survey on the internet [GO TO Q35E]

2. I prefer to complete a paper survey and mail it back

[if TOKEN=03 GO TO Q35A. Else go to thank you screen]

3. I prefer for someone to call me so I can complete the survey over the phone [GO TO Q35P]

Q35E. Please provide an email address where we may contact you.

_________________________________________

[Go to thank you screen]

Q35A. Please confirm that your mailing address is:

[FILL NAME AND MAILING ADDRESS FROM SAMPLE FILE]

01 My address is correct. [Go to thank you screen]

02 My address is NOT correct. [go to Q35ADD]

03 Please do NOT send a gift card. [Go to thank you screen]

Q35ADD

Please enter your mailing address.

FIRST AND LAST NAME _____________

STREET ADDRESS __________________________

CITY ____________________

STATE ________________________

ZIP CODE _________________________

[Go to thank you screen]

Q35P. Please provide a telephone number, including area code, where an interviewer can reach you.

_ _ _-___-____

[Go to thank you screen]

[thank you screen]

Thank you for participating! If you have any questions, you can contact the study team at xxxx@norc.org