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Program tool 20.
Sample questions for members
Falls prevention questions
1. For each of the following, please indicate, by
checking the appropriate box, how strongly you disagree or agree
with each statement. There are NO right or wrong answers. We are
interested in your opinions.
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Strongly disagree |
Disagree |
Agree |
Strongly agree |
Don’t know |
| It does not matter what seniors
do to avoid falling, they are going to fall anyway. |
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| Using a cane makes you (would
make you) feel old. |
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| It is up to building owners
to remove hazards from their buildings |
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| Seniors in this organization
are not very interested in making it safer from falls |
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| It is really difficult to change
things in neighbourhoods to make them safer. |
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| Telling seniors how to reduce
their risk of falling is butting into other people’s business. |
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| Implementing falls prevention
initiatives would be a waste of time and money. |
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| It is hard for seniors to learn
anything new about preventing falls. |
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| Only young people can improve
their strength and stamina by exercising. |
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| If I tell others about a fall,
they might start to think that I am too frail to live by myself. |
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2. Please read the following list of common
daily activities and indicate, by checking the appropriate box,
how confident you are that you can do these activities at this time.
| How confident are you that you could perform
each activity? |
Not at all confident |
Fairly confident |
Completely confident |
| You could learn ways of preventing
falls. |
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| You could follow a daily exercise
routine. |
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| You could take a daily walk
outside for exercise. |
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| If you were on medications
and experiencing side effects, you could ask your doctor to
change your medication. |
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| You could make changes to your
home to reduce fall hazards. |
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| You could attend a meeting
with other seniors in this organisation to discuss what seniors
can do to prevent falls. |
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| You could walk up and down
a flight of stairs without falling. |
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| You could walk around inside this centre/legion without falling. |
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| You could walk in your community
without falling. |
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| You could get in/out of a chair
without falling. |
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3. Think back over the last twelve months. Have
you had any falls during that time? (By a fall, we mean an event
where you landed on the ground, tripped on the stairs, slipped,
or lost your balance and hit against an object like a chair or bed.)
 Yes No
If YES, how many falls have you had in the last four
months? ________________
Active living questions
1. Now please tell us how much you agree with each
of the following statements about physical activity. Even if you
do not exercise on a regular basis, we would like you know your
thoughts.
Do you believe that regular physical activity…
(If you do not engage in regular physical activity, do you believe
that it…) |
Strongly disagree |
Disagree |
Agree |
Strongly agree |
Don’t know |
| Improves (would improve) your
mood |
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| Helps (would help) you to sleep
better |
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| Gives (would give) you energy |
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| Makes (would make) you feel
more mentally alert |
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| Helps (would help) you to carry
out your normal activities without getting too tired |
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| Increases (would increase)
your physical fitness |
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| Improves (would improve) the
way your body looks |
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| Decreases (would decrease)
your tension and stress |
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| Gives (would give) you a sense
of personal accomplishment |
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| Decreases (would decrease)
your risk of a severe injury if you were to fall |
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2. How confident are you that you can exercise when
other things get in the way?
| How confident are you that
you could exercise when |
Not at all confident |
Somewhat confident |
Moderately confident |
Very confident |
Completely confident |
| You are under a lot of stress |
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| You feel like you do not have
the time |
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| You have to exercise alone |
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| You don’t have access
to exercise equipment |
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| You are spending time with
friends and family who do not exercise |
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| It’s raining or snowing
outside |
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3. What best describes your activity level?
Vigorously active for at least 30 minutes 3 times per week (exercise program, brisk walking, Tai Chi, swimming)
Moderately active at least 3 times per week (gardening, walking, housework)
Seldom active, preferring more sedentary activities
(reading, playing cards, watching television)
4. Compared to other people your own age, do you think
you are: (Please check box)
Much more active
More active
About as active
Much less active
5. Have you ever called your city or local authority
to report a fall hazard in your community?
Yes
No If yes, how many calls have you made in the last
year? ______
| Active Independent Aging was a joint venture between the University of Ottawa and the Public Health and Long-term Care Branch, City Of Ottawa. For more information please visit our website at: www.falls-chutes.com. Funding provided by Health Canada/Veterans Affairs Canada Falls Prevention Initiative. The views expressed herein do not necessarily represent the official policies of Health Canada, Veterans Affairs Canada, the University of Ottawa and the Public Health and Long-term Care Branch, City Of Ottawa. The information in this handout is current as of 2004. |
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