Form 0920-19ARD Follow-up Survey

Attachment B2. Patient Follow-up Survey

Form Approved OMB No: 0920-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 (0920-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 continued help with this important study. Your participation is voluntary. You can refuse to answer a question or stop the interview at any time, and all information you provide is confidential, and will only be used for the purposes of this study.

Q1. In general, would you say that your health is:

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

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.

If you have your falls tracking log available, please use it to help you answer the remaining questions.

Q2. Since the last time you took this survey, have you fallen?

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

If yes go to Q3. If No, DK, REF, go to Q10.

Q3. How many times did you fall since the last time you took this survey?

_______ Number of falls

If 0 go to Q10. Else go to Q4.

Q4_INTRO. Starting with the most recent fall, please answer the following items about up to three falls you had since you last took this survey.

Thinking of the most recent fall:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q4. Did the fall cause an injury? By injury, we mean the fall caused you to limit your regular activities for at least a day or go seek a health care professional.	□	□	□	□
Q5. Did you get medical attention?	□ go to Q5a	□ If Q3=1, go to Q10. Else go to Q6.	□ If Q3=1, go to Q10. Else go to Q6.	□ If Q3=1, go to Q10. Else go to Q6.
Q5a. Was the medical attention you received provided by an Emory provider?	□	□	□	□

Q5b. What kind of medical attention did you receive? Please select all that apply.

1 Emergency Medical Services (EMT, Ambulance)	2 Emergency Room Visit	3 Urgent Care Visit	4 Doctor’s Office Visit	5 Admitted to Hospital	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

If Q3=1, go to Q10_INTRO. Else go to Q6.

Thinking of the second most recent fall:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q6. Did the fall cause an injury? By injury, we mean the fall caused you to limit your regular activities for at least a day or go seek a health care professional.	□	□	□	□
Q7. Did you get medical attention?	□ go to Q7a	□ If Q3=2, go to Q10. Else go to Q8.	□ If Q3=2, go to Q10. Else go to Q8.	□ If Q3=2, go to Q10. Else go to Q8.
Q7a. Was the medical attention you received provided by an Emory provider?	□	□	□	□

Q7b. What kind of medical attention did you receive? Please select all that apply.

1 Emergency Medical Services (EMT, Ambulance)	2 Emergency Room Visit	3 Urgent Care Visit	4 Doctor’s Office Visit	5 Admitted to Hospital	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

If Q3=2, go to Q10_INTRO. Else go to Q8.

Thinking of the third most recent fall:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q8. Did the fall cause an injury? By injury, we mean the fall caused you to limit your regular activities for at least a day or go seek a health care professional.	□	□	□	□
Q9. Did you get medical attention?	□ go to Q9a	□ go to Q10	□ go to Q10	□ go to Q10
Q9a. Was the medical attention you received provided by an Emory provider?	□	□	□	□

Q9b. What kind of medical attention did you receive? Please select all that apply.

1 Emergency Medical Services (EMT, Ambulance)	2 Emergency Room Visit	3 Urgent Care Visit	4 Doctor’s Office Visit	5 Admitted to Hospital	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q10_INTRO. IF SURV_NUM=1 DISPLAY: Recently you visited your Emory provider and participated in a falls risk screening. Our records indicate that visit took place on XX/XX/XXXX. Since that visit, has a health care professional done any of the following: ELSE DISPLAY: Since the last time you took this survey, has a health care professional done any of the following:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q10. Referred you to physical therapy?	□	□	□	□
Q11. Referred you to occupational therapy?	□	□	□	□
Q12. Referred you to an exercise program (such as Tai Chi or yoga)?	□	□	□	□
Q13. Referred you to an eye doctor?	□	□	□	□
Q14. Referred you to a foot doctor?	□	□	□	□
Q15. Recommended a change to one or more of your medications?	□	□	□	□
Q16. Recommended you use a cane or walker?	□	□	□	□
Q17_INTRO. IF SURV_NUM=1 DISPLAY: Since the Emory visit, have you done any of the following: ELSE DISPLAY: Since the last time you took this survey, have you done any of the following:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q17. Gone to physical therapy?	□	□	□	□
Q18. Gone to occupational therapy?	□	□	□	□
Q19. Visited an eye doctor?	□	□	□	□
Q20. Visited a foot doctor?	□	□	□	□
Q21. Stopped, switched, or reduced one or more of your medications?	□	□	□	□
Q22. Used a cane or walker?	□	□	□	□
Q23. Reviewed brochures or other materials on how to prevent falls?	□	□	□	□

	1 Tai Chi	2 Matter of Balance	3 Other Exercise	77 Don’t know	99 Prefer not to Answer
Q24. IF SURV_NUM=1 DISPLAY: Since the Emory visit, have you… ELSE DISPLAY: Since the last time you took this survey, have you participated in any of the following exercise programs: Tai Chi, Matter of Balance, or some other exercise?	□	□	□	□	□

Q25_INTRO. IF SURV_NUM=1 DISPLAY: Since the Emory visit, have you made any of the following changes to your home to prevent falls: ELSE DISPLAY: Since the last time you took this survey, have you made any of the following changes to your home to prevent falls:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q25. Installed handrails	□	□	□	□
Q26. Replaced stairs with ramps	□	□	□	□
Q27. Removed clutter	□	□	□	□
Q28. Removed mats/rugs	□	□	□	□
Q29. Removed loose cords	□	□	□	□
Q30. Improved lighting	□	□	□	□
Q31. Repaired unsafe/unsteady furniture	□	□	□	□
Q32. Moved furniture	□	□	□	□
Q33. Moved to a safer home	□	□	□	□

Do you take:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q34. Medicine prescribed for you to help you sleep such as zolpidem (Ambien), zaleplon (Sonata), or eszopiclone (Lunesta)?	□	□	□	□
Q35. Over-the-counter medicine to help you sleep such as diphenhydramine (Benedryl, ZZZQuil, Tylenol PM) or doxylamine (Unisom)?	□	□	□	□
Q36a. 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).	□	□	□	□
Q36b. Non-opioid medicine prescribed for you to help with pain, such as ibuprofen (Motrin), naproxen (Naprosyn), or diclofenac (Voltaren)?	□	□	□	□
Q37. Over the counter medicine to help with pain such as ibuprofen (Motrin, Advil), acetaminophen (Tylenol) or naproxen (Aleve)?	□	□	□	□
Q38. Medicine prescribed for you to help your mood or for sadness, such as sertraline (Zoloft), citalopram (Celexa), or duloxetine (Cymbalta)?	□	□	□	□
Q39. Medicine prescribed for you to help with anxiety or nervousness, such as alprazolam (Xanax), lorazepam (Ativan), or diazepam (Valium)?	□	□	□	□
Q40. Medicine prescribed for you to help with mood stability, such as risperidone (Risperdal), aripiprazole (Abilify), or quetiapine (Seroquel)?	□	□	□	□
Q41. Vitamin D or a multivitamin?	□	□	□	□

Q42. How many prescription medications do you take regularly?

______ number of medications

Q43. 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
□	□	□	□	□	□

Q44. Did you use marijuana in the last 30 days?

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

If SURV_NUM=3 THEN GO TO Q45. ELSE GO TO TOKEN. DEFINE SURV_NUM AS 1,2,3, WILL BE IN THE SAMPLE FILE TO DISTINGUISH BETWEEN ROUNDS OF THE QUARTERLY SURVEY

[asked only in the last quarterly survey]

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:	1 Strongly Disagree	2 Disagree	3 Neither Agree nor Disagree	4 Agree	5 Strongly Agree	77 Don’t Know	99 Prefer not to Answer
Q45. Older people fall and there is nothing that can be done about it.	□	□	□	□	□	□	□
Q46. There are things I can do to reduce my risk of falling.	□	□	□	□	□	□	□

TOKEN. Those are all the questions. Thank you for taking the time to participate today.

[IF SURV_NUM<3 DISPLAY: 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 thank you screen]

02 My address is NOT correct. [go to Q34ADD]

03 Please do NOT send stamps. [Go to thank you screen]

Q34ADD

Please enter your mailing address.

FIRST AND LAST NAME _____________

STREET ADDRESS __________________________

CITY ____________________

STATE ________________________

ZIP CODE _________________________

[thank you screen]

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