1. Why did you join the Walk n Talk for Your Life program? Please check all that apply.

Transcription

1 Wa l k n Tal k Seniors Walk n Talk for your Life! for yo ur Lif e! Today s Date: Day / Month / Year Participant Number: First Name: Last Name: Date of Birth: Day / Month / Year Gender (M or F): I. Basic Information About You 1. Why did you join the Walk n Talk for Your Life program? Please check all that apply. I want to exercise more. I want to socialize more. I want to learn more about health and wellbeing. Other. Please specify: 2. How did you hear about the Walk n Talk for Your Life program? Please check all that apply. An online/internet ad A poster Friend(s) Family member(s) Other. Please specify: 3. What do you hope to gain from the Walk n Talk for Your Life program? Please check all that apply. Have more fun. Meet new people. Improve my mobility. Improve my balance. Improve my flexibility. Improve my physical activity level. Improve my strength and stamina. Learn about a healthy diet and lifestyle. Improve my mental and/or emotional wellbeing. Other. Please specify: H : Seniors WTL Version 5: Nov 17, Page 1 of 12

2 4. Please check one box that best describes your living situation. I am currently living: Alone With someone 5. Please check one box that best describes your marital status. I am currently: Single and never married Common-law Divorced Married Separated Widowed 6. Please check one box that best describes you. I think of myself as: White Black rth American Indian Métis Inuit Chinese Filipino Japanese Korean Latin American Arab West Asian (Iranian, Afghan, etc.) Southeast Asian (Vietnamese, Cambodian, Malaysian, Laotian, etc.) South Asian (East Indian, Pakistani, Sri Lankan, Bangladeshi, etc.) Other. Please specify: 7. Please check one box. My highest level of education is: Less than high school High school graduate (or equivalent) Vocational, trade or business school Some college or university College or university graduate Graduate studies or graduate degree 8. Please check one box. My annual income range is: $0 to $25,000 $26,000 to $50,000 $51,000 to $75,000 $76,000 to $100,000 over $100,000 H : Seniors WTL Version 5: Nov 17, Page 2 of 12

3 II. Your Thoughts on Diet and Physical Activity For each statement in the table below, please check one box that indicates how much you agree with the statement. People can reduce their risk of stroke (brain attack) by eating more fruits and vegetables. People can reduce their risk of cancer by eating more fruits and vegetables. People can reduce their risk of back pain by eating more fruits and vegetables. People can reduce their risk of heart disease by eating more fruits and vegetables. Physical activity can improve balance in older people. Physical activity can reduce the risk of falling in older people. Strongly Agree Agree Neutral Disagree Strongly Disagree Don t Know 1. For people your age, how many servings of fruits and vegetables do experts recommend eating every day? Three or less Four Five Six Seven or more I don t know. 2. For people your age, how many servings of milk or alternatives (e.g., cheese, yogurt) do experts recommend eating every day? One Two Three Four I don t know. H : Seniors WTL Version 5: Nov 17, Page 3 of 12

4 3. For people your age, how many minutes of physical activity per day do experts recommend? I don t know. 4. In Canada, are there physical activity guidelines for older adults? Yes I don t know. III. Your General Health and Activity 1. Overall, how do you personally rate your health and wellbeing? Please check one box. Very Good Good Fair t So Good Poor 2. Do you ever use any mobility or balance aids? Yes -----> What type? Please check all that apply. A walking stick/pole/cane A walker A wheelchair Other: 3. Do you currently exercise at all? Please check all that apply. Yes, I exercise in a group. Yes, I exercise alone. H : Seniors WTL Version 5: Nov 17, Page 4 of 12

5 4. At the present time, do you smoke cigarettes daily, occasionally or not at all? Daily Occasionally t at all -----> Please go to Question On the days that you smoke, how many cigarettes do you usually smoke each day? cigarettes 6. In the past month, on how many days have you smoked 1 or more cigarettes? days 7. Please tell us the type and amount of physical activity involved in your work: I am not in employment (e.g. retired, retired for health reasons, unemployed, fulltime caregiver, etc.) I spend most of my time at work sitting (such as in an office) I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder, etc.) My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.) My work involves vigorous physical activity including handling of very heavy objects (e.g. construction worker, garbage collector, etc.) Please check one box only. 8. During the last week, how many hours did you spend on each of the following activities? Please answer whether you are employed or not. Please mark one box only on each row. Swimming, jogging, aerobics, football, tennis, gym workout etc. Cycling, including cycling to work and during leisure time Walking, including walking to work, shopping, for pleasure etc. None Less than 1 hour More than 1 hour but less than 3 hours 3 hours or more Housework/Childcare Gardening/Do-It-Yourself Activities H : Seniors WTL Version 5: Nov 17, Page 5 of 12

6 9. How would you describe your usual walking pace? Please check one box only. slow pace (i.e., less than 3 miles per hour) steady average pace brisk pace fast pace (i.e., more than 4 miles per hour) IV. Your Social Connections 1. For the following statements, circle how often each of the statements below is descriptive of you. Please check one box ( ) for each row. Statement Never Rarely Sometimes Often 1. How often do you feel in tune with the people around you? 2. How often do you feel that you lack companionship? 3. How often do you feel there is no one you can turn to? 4. How often do you feel alone? 5. How often do you feel a part of a group of friends? 6. How often do you feel you have a lot in common with the people around you? 7. How often do you feel you are no longer close to anyone? 8. How often do you feel your interests and ideas are not shared by those around you? 9. How often do you feel you are an outgoing person? 10. How often do you feel close to people? 11. How often do you feel left out? 12. How often do you feel your relationships with others are not meaningful? 13. How often do you feel that no one really knows you well? 14. How often do you feel isolated from others? 15. How often do you feel you can find companionship when you want it? 16. How often do you feel there are people who really understand you? 17. How often do you feel shy? 18. How often do you feel there are people around you but not with you? 19. How often do you feel that there are people you can talk to? 20. How often do you feel there are people you can turn to? H : Seniors WTL Version 5: Nov 17, Page 6 of 12

7 FAMILY: Considering the people to whom you are related by birth, marriage, adoption, etc. 1. How many relatives do you see or hear from at least once a month? Please check one box. none one two three or four five through eight nine or more 2. How many relatives do you feel at ease with that you can talk about private matters? Please check one box. none one two three or four five through eight nine or more 3. How many relatives do you feel close to such that you could call on them for help? Please check one box. none one two three or four five through eight nine or more FRIENDSHIPS: Considering all of your friends including those who live in your neighborhood. 4. How many of your friends do you see or hear from at least once a month? Please check one box. none one two three or four five through eight nine or more H : Seniors WTL Version 5: Nov 17, Page 7 of 12

8 5. How many friends do you feel at ease with that you can talk about private matters? Please check one box. none one two three or four five through eight nine or more 6. How many friends do you feel close to such that you could call on them for help? Please check one box. none one two three or four five through eight nine or more For each of the 11 statements, please indicate the extent to which they apply to your situation, the way you feel now. Please check one box for each statement. Statement Yes More or Less 1. There is always someone I can talk to about my day-to-day problems. 2. I miss having a really close friend. No 3. I experience a general sense of emptiness. 4. There are plenty of people I can lean on when I have problems. 5. I miss the pleasure of the company of others. 6. I find my circle of friends and acquaintances too limited. 7. There are many people I can trust completely. 8. There are enough people I feel close to. 9. I miss having people around me. 10. I often feel rejected. 11. I can call on my friends whenever I need them. H : Seniors WTL Version 5: Nov 17, Page 8 of 12

9 V. Your Hearing Instructions: Please check yes, no, or sometimes in response to each of the following items. Do not skip a question if you avoid a situation because of a hearing problem. If you use a hearing aid, please answer the way you hear without the aid. Item Yes Sometimes No Does a hearing problem cause you to feel embarrassed when meeting new people? Does a hearing problem cause you to feel frustrated when talking to members of your family? Do you have difficulty hearing when someone speaks in a whisper? Do you feel handicapped by a hearing problem? Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? Does a hearing problem cause you to attend religious services less often than you would like? Does a hearing problem cause you to have arguments with family members? Does a hearing problem cause you difficulty when listening to TV or radio? Do you feel that any difficulty with your hearing limits or hampers your personal or social life? Does a hearing problem cause you difficulty when in a restaurant with relatives or friends? VI. Your History of Falling and Your Confidence with Your Balance 1. Have you had any falls in the last 3 months? This includes any slip, trip, stumble, fall the ground or floor, or fall to a lower level > Yes -----> Please go to the Activities-Specific Balance Confidence (ABC) Scale on the next page. How many times did you fall in the last 3 months? times. I don t remember. In the last 3 months, were you injured or did you seek medical assistance because of a fall? Yes I don t remember. H : Seniors WTL Version 5: Nov 17, Page 9 of 12

10 The Activities-Specific Balance Confidence (ABC) Scale For each of the following, please indicate your level of confidence in doing the activity without losing your balance or becoming unsteady. Choose one of the percentage points on the scale from 0% (no confidence) to 100% (completely confident). If you do not currently do the activity in question, try and imagine how confident you would be if you had to do the activity. If you normally use a walking aid to do the activity or hold onto someone, rate your confidence as if you were using these supports. If you have any questions about answering any of these items, please ask. 0% % no completely confidence confident How confident are you that you will not lose your balance or become unsteady when you walk around the house? % walk up or down stairs? % bend over and pick up a slipper from the front of a closet floor? % reach for a small can off a shelf at eye level? % stand on your tiptoes and reach for something above your head? % stand on a chair and reach for something? % sweep the floor? % walk outside the house to a car parked in the driveway? % get into or out of a car? % walk across a parking lot to the mall? % walk up or down a ramp? % walk in a crowded mall where people rapidly walk past you? % are bumped into by people as you walk through the mall? % step onto or off an escalator while you are holding onto a railing? % step onto or off an escalator while holding onto parcels such that you cannot hold onto the railing? % walk outside on icy sidewalks? % H : Seniors WTL Version 5: Nov 17, Page 10 of 12

11 VII: Geriatric Depression scale: Questions about your mood: Please circle the best answer for how you felt over the past week: No. Question Score 1 Are you basically satisfied with your life? Yes / No 2 Have you dropped many of your activities and interests? Yes / No 3 Do you feel that your life is empty? Yes / No 4 Do you often get bored? Yes / No 5 Are you in good spirits most of the time? Yes / No 6 Are you afraid that something bad is going to happen to you? Yes / No 7 Do you feel happy most of the time? Yes / No 8 Do you often feel helpless? Yes / No 9 Do you prefer to stay at home, rather than going out and Yes / No doing new things? 10 Do you feel you have more problems with memory than most people? Yes / 11 Do you think it is wonderful to be alive? Yes / No 12 Do you feel pretty worthless the way you are now? Yes / No 13 Do you feel full of energy? Yes / No 14 Do you feel that your situation is hopeless? Yes / No 15 Do you think that most people are better off than you Yes / No are? Total No VIII. About This Program Yes 1. Are you interested in volunteering in some way with the Walk n Talk for Your Life program? We will be discussing possible volunteer opportunities in our sessions. 2. Do you know anyone that you think would benefit from a program like this but who may not be able to come for some reason? Yes -----> Are you willing to tell them about the program and suggest that they contact us? Yes H : Seniors WTL Version 5: Nov 17, Page 11 of 12

12 My Contact Information First Name Last name Address: Home Phone : Mobile Phone: address: My Emergency Contact Person First Name: Last Name: Phone numbers Work Phone: Home Phone: Mobile Phone: H : Seniors WTL Version 5: Nov 17, Page 12 of 12