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Fall Screening Test

Participant Information

 
 
 
 
 

Gender
Male
Female

Marital Status
Single
Married
Widowed
Divorced
Declined to answer

Ethinicity
White or Caucasian
Black or African American
American Indian / Alaskan Native
Hispanic or Latino(Mexican, Puerto Rican, Cuban, Other)
Asian(Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other)
Native Hawaiian and other Pacific Islander
Other
Declined to answer

Income
$776 or less monthly
$1041 or less monthly
$1306 or less montly
$1571 or less monthly
$1836 or less monthly
Annual $25,000 to $34,999
Annual $35,000 to $49,999
Annual $50,000 or greater
Declined to answer

Household Size
1 Person
2 Person
3 Person
4 Person
5 Person
Declined to answer

Education Level
Less than 9th Grade
High School Graduate/GED
Some College, No Degree
Associated Degree
Bachelors Degree
Graduate or Professional Degree
Declined to answer

History of Diseases


Medical/Fall History

Age


Fall 1
Have you fallen in the past 3 years?
Yes
No

Fall 2
If yes to Fall 1, were any within the last 12 months?
Yes
No
N/A

Do you use any walking aids(cane, walker etc..)?
Yes
No

Do you have Arthritis?
Yes
No

Mobility/Balance

Functional Reach Test(inches)


Expanded Time Up and Go(seconds)
(Enter any ONE value)
10m Test
3m Test

Medications

Known Medications include (check all the apply)
If you are uncertain of your medications click here
4 or more prescription meds
Psychotrophic Meds
Anti-arrhythmic Meds
Digoxin/Lanoxin
Diuretics
None of the above

Have you experienced any side-effects due to your medications(e.g: Drowsiness, Dizziness, impaired balance)?
Yes
No
N/A

Do you fill ALL your prescriptions at the same pharmacy or had a pharmacist review your current medications?
Yes
No
N/A


Vision

Do you have a prescription for corrective lenses?
Yes
No

If YES, Do you wear your corrective lenses as prescribed?
Yes
No
N/A

Have you had a vision test in the past 12 months?
Yes
No

Snellen Score w/lenses
20 /

Environment Survey

If you have stairs within your home or to enter your home answer questions 1, 2 and 3. If not skip to question 4.

1. Do you have handrails on both the sides of all the stairways in your home - including the outside stair?
Yes
No
N/A

2. Do the stair rails extend the full length of the stairway?
Yes
No
N/A

3. Are the stairways well lit with lights at the top and bottom of the stairs?
Yes
No
N/A

4. Do you have nightlights to help light your bathrooms, bedrooms and hallways during evening hours?
Yes
No

5. Are you able to turn on a light immediately upon entering a room?
Yes
No

6. Do you have grab bars in your bath and shower stalls as well as on the sides of the toilet?
Yes
No

7. Do you have non-slip mat or safety decals in your bath and shower?
Yes
No

8. Do you remove soap build-up in the tub and shower on a regular basis to avoid slipping?
Yes
No

9. If you have area rugs, do they have rug-liners underneath, dual-sided tape or non-skid backs?
Yes
No
N/A

10. Are your steps, landings and floors clear of clutter?
Yes
No

11. Do you keep floors clean by promtly wiping up grease, water and other spills?
Yes
No

12. Are things you use often stored on easy-to-reach shelves, so that you don't need to reach too high or bend too low to get them?
Yes
No

I have double checked the values entered

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