HEALTH BEHAVIOR CHANGE SURVEY

Transcription

1 HEALTH BEHAVIOR CHANGE SURVEY First Name Last Name Where did you take Stepping On? City County What month did it start? Since you ve taken Stepping On 1. Did you discuss falls with your Primary Physician? 2. If you already had an assistive device, are you using it more? 3. Did you get a new or different assistive device? IF YES, Are you using it? 4. Did you get physical therapy to help with your balance? 5. Did you do your shoe audit? If YES, did you take any necessary action to improve your footwear? Didn t need any changes 6. Did you see an eye doctor? 1

2 7. Did you cut down or stop anything you were taking for sleep? 8. Did you talk with your doctor about any of your medications and falls risk? If YES, did your medications change? 9. Are you continuing your Stepping On exercises? Partially 10. Have you joined a community exercise program since Stepping On? Partially 11. Did you find you need more Vitamin D? IF YES, are you taking more Vitamin D? 2

3 Participant Name: The Falls Behavioral Scale The Falls Behavioral Scale is a list of 24 statements that describes things we do in our everyday lives. Please read each statement carefully. Circle how much each statement describes the things you do in your daily life. For example, I do things at a slower pace. If you do things slowly once in a while, circle Sometimes. Only circle Doesn t apply if the situation is something to which you are not exposed to. For example, if you do not have a phone, you would circle Doesn t apply. Would this describe the things you do in your daily life? Circle which one applies 1. When I stand up, I pause to get my balance. 2. I do things at a slower pace. 3. I talk with someone I know about things I do that might help prevent a fall. 4. I bend over to reach something only if I have a firm handhold. 5. I use a walking stick or walking aid when I need it. 6. When I am feeling unwell, I take particular care doing everyday things. 7. I hurry when I do things. 8. I turn around quickly. Now, these are things you do indoors 9. To reach something up high, I use the nearest chair, or whatever furniture is handy, to climb on. 10. I hurry to answer the phone. 11. I get help when I need to change a light bulb. 12. I get help when I need to reach something very high. 13. When I am feeling ill, I take special care 3

4 of how I get up from a chair and move around. 14. When I am getting down from a ladder or step stool, I think about the bottom rung/step. Doesn t Apply Now, these are about lighting and eyesight Would this describe the things you do in your daily life? Circle which one applies 15. I use a light if I get up during the night. 16. I adjust the lighting at home to suit my eyesight. Now, these are about shoes 17. When I buy shoes, I check the soles to see if they are slippery. Now, these are about things outdoors 18. When I walk outdoors, I look ahead for potential hazards. 19. I avoid ramps and other slopes. 20. I go out on windy days. 21. When I go outdoors, I think about how to move around carefully. 22. I cross at traffic lights or pedestrian crossings whenever possible. 23. I hold onto a handrail when I climb stairs. 24. I avoid walking about in crowded places. 4

5 Health Care and Mobility Falls Information 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. 1. In the Past 3 months, how many times have you fallen? If you can only remember the approximate number of falls, that is okay. Try to enter a number as close to your number of falls as you can remember. (Only enter one number.) None times Don t know 2. If you fell in the past 3 months, 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 3. How fearful of you of falling? Not at all A little Somewhat A lot 4. In the past 3 months, how many different times did you go to a hospital emergency department because of injuries due to a fall? (Write 0 or another number). Visits Don t know 5. In the past 3 months, how many different times did you stay in a hospital overnight or longer because of injuries due to a fall? (Write 0 or another number). Times Don t know 6. How many total nights did you spend in the hospital in the past 3 months because of injuries due to a fall? (Write 0 or another number). Number of nights Don t know 5

6 7. Please, check the box that tells us how sure you are that you can do the following activities. How sure are you that: Very Sure Sure Somewhat 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 protect myself if I fall d. I can increase my physical strength e. I can become more steady on my feet Not at all sure 8. 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? Extremely Quite a bit Moderately Slightly Not at all Thank you for your assistance in measuring the effectiveness of this program! If you have any questions or comments, please contact: Jane Mahoney, MD UW Department of Medicine-Geriatrics Executive Director, Wisconsin Institute for Healthy Aging 1414 MacArthur Road, Suite B Madison, WI (608)