1 |
In the last month, have you felt (you may mark more than one answer): |
|
a) Dizziness when standing or walking |
|
b) Weakness in your whole body |
|
c) Weakness only in your arms |
|
d) Weakness only in your legs |
|
e) Difficulty to walk |
|
f) Tiredness or exhaustion |
2 |
In the last year, do you feel your strength has decreased when performing simple tasks, e.g., climbing stairs or steps, opening containers, carrying grocery bags, cleaning or tidying the house? |
|
( ) Yes |
|
( ) No |
3 |
Do you feel the way you walk has become slower in the last year, in comparison to the year before that? |
|
( ) Yes |
|
( ) No |
4 |
When you walk, do you need some form of support or device (for example: cane, crutches, or help of another person)? |
|
( ) Yes |
|
( ) No |
5 |
Do you exercise regularly, for example: walking, cycling, going to the gym, doing aerobics, playing soccer or volleyball, at least twice a week for at least 30 minutes each day? |
|
( ) Yes |
|
( ) No |
|
If the answer for question 5 is “yes”, the interviewee is asked how long he/she has been exercising. |
5.1 |
How long have you been exercising regularly (that is, without stopping for any period of time)? |
|
a) Less than one year |
|
b) 1 to 2 years |
|
c) 2 to 3 years |
|
d) 3 to 5 years |
|
e) More than 5 years |
6 |
Do you believe your ability to perform daily tasks, such as walking, going uphill, tidying the house, has decreased in comparison to the previous year? |
|
( ) Yes |
|
( ) No |
7 |
In the last year, have you lost weight or have your clothes become loose, without you having changed the amount of food you eat? |
|
( ) Yes |
|
( ) No |
|
If the answer to question 7 is “yes”, the interviewee is asked how many kilos he/she has lost. |
7.1 |
a) Lost between 1kg and 3kg |
|
b) More than 3kg |
8 |
Did you fall in the last year? |
|
( ) Yes |
|
( ) No |
|
If the answer to question 8 is “yes”, the interviewee is asked four more questions about the fall. If the answer to question 8 is “no”, the questionnaire is over. |
8.1 |
How many times did you fall in this period (last year)? |
|
a) once |
|
b) twice |
|
c) three times |
|
d) more than three times |
8.2 |
Where were you when you fell (you may mark more than one option if you have fallen more than once): |
|
a) At home (bedroom, bathroom, kitchen, living room) |
|
b) In the backyard of your home (yard or garden) |
|
c) On the street (sidewalk, curb, slippery sidewalk, at work, sports club, at the gym) |
8.3 |
How did you fall (you may mark more than one option if you have fallen more than once)? You: |
|
a) Were standing and fell |
|
b) Were walking and fell |
|
c) Were walking, tripped and fell |
|
d) Fell down a staircase |
|
e) Fell from a chair (you were sitting and fell or were in the act of sitting and fell) |
|
f) Other |
8.4 |
Because of the fall, you (you may mark more than one option): |
|
a) Had no consequences |
|
b) Had to be admitted to the hospital |
|
c) Suffered a fracture (broken bone) |
|
d) Had difficulty walking after the fall |
|
e) Have permanent (forever) difficulty to perform daily activities, such as brushing your hair, getting dressed, taking a shower, or eating on your own |
|
f) Can no longer perform tasks on your own, such as doing the dishes, tidying the house, grocery shopping, cooking for yourself, answering the door, taking a bus or riding in a car) |
|
g) Are afraid to fall again |
|
h) Are apprehensive about performing daily activities for fear of falling again |