APPENDIX 1: The 1996 Hunei Study Questionnaire
1996 SURVEY OF FREQUENCY AND CAUSAL FACTORS OF FALLS AMONG THE ELDERLY OF HUNEI VILLAGE, KAOHSIUNG, TAIWAN 

Sample No: (To be filled in 
          by interviewer)

Village (Tsun)     Sequence
Code No.         No.	
Sponsored by: Taiwan Provincial Department of Health (No. 093832) (Copyrightc 2001 Bureau of Health Promotion, Taiwan: All rights reserved) 
Conducted by: Taiwan Provincial Institute of Family Planning (No. 149)
Assisted by: Hunei, Kaohsiung, Health Station Group Medical Center; Institute of Public Health, National Yang-Ming University; Department of Medical Management, Institute of Technology, Chang-Kung Hospital    
Respondent’s name:                                               	
Tel: (Day)                   		(Eves)                          
Address:                                                        
Type of Dwelling:
___1 Multi-story dwelling (no. of floors___) 	__2 Single-story dwelling	
___3 Apartment (___floor)	___4 Compound with houses surrounding a courtyard ___5 Senior citizens’ home	___6 Other, please explain:____________________
Sex:  ___M	___F		D.O.B.:_____Y_____M_____D

Change of Address Form:
Order No.	Respondent’s New  Address *	Tel.	Remarks	
1				
2				
*Note: Include all information that was helpful in tracing the respondent’s new address.

___1 Interview completed	___2 Interview mostly completed 	___3 Other
No. of interviews: ____		Interview completion date: _____M _____D
Interviewer’s Name:___________________________________________ 	
INTERVIEWER: DO NOT WRITE BELOW THIS LINE.                 
Question Numbers for Make-up Interview:______________________________
Reviewer: ____________________    
Coder: _______________________
INSTRUCTIONS FOR INTERVIEWER:
1. 	Skip questions only when requested to do so in the instructions.  Otherwise, continue to ask questions in order.
2. 	If the respondent’s reply does not match any of the answer choices, please write in the respondent’s reply. 
3. 	If the respondent is unable to answer a question, please place a question mark next to that question.  Do not leave it blank, or the respondent will be asked the question again during a make-up interview.

RESPONDENT OR PROXY?
(ATTENTION INTERVIEWER: FOR ANY OF THE FOLLOWING SITUATIONS, DO NOT USE THIS QUESTIONNAIRE.)
1. 	The respondent is in Taiwan, but has moved away from Hu-nei Village.  Or, the respondent usually lives somewhere else or is out of the country and will not return for more than one month.  Or, physical or mental health is not good, and there is no suitable proxy.
2. 	Unable to find the respondent, or respondent refuses the interview, or the interview is interrupted, and cannot be completed.
3. 	The respondent is deceased.  Ask the date and cause (including type of illness) of death.  In addition, obtain a copy of the respondent’s death certificate and fill out the Deceased Respondent Report Form.
(This section is to be filled in by the interviewer.)

I1. The time at the start of the interview:  ___1 AM	___2 PM	(Time:_______)

I2. The person being interviewed is:
	___1 The respondent him/herself (Skip to Section A) 
	___2 Proxy  I2.1 What is the proxy’s relationship to the respondent?
					_______________________________________
					(Enter one of the following code numbers)
	01 Spouse		07 Granddaughter		13 Grandson’s wife
	02 Son			08 Parent				14 Granddaughter’s husband
	03 Daughter-in-law	09 Brother			15 Other relative
	04 Daughter		10 Sister				16 Friend
	05 Son-in-law		11 Husband’s parent	17 Caregiver
	06 Grandson		12 Wife’s parent		18 Other ______________

I3. The reason for using a proxy is:
A. 	At the start of the interview one of the following situations occurred, thus a proxy was found:
01 The respondent was seriously ill or too weak to be interviewed
02 The respondent was hard of hearing, deaf or mute
03 The respondent was mentally unclear
04 The respondent is overseas or out-of-town and will not return for at least one month
05 The respondent is deceased
06 Other (please specify):___________________________________

B. 	During the interview, one of the following situations occurred, and thus, a proxy was found to replace the respondent for the rest of the interview:
07 The respondent could not remember the questions
08 The respondent was obviously unreasonable
09 The respondent was unwilling to continue, refused to answer
10 The respondent was in low spirits or depressed
11 Other (please specify)____________________________________

A. BACKGROUND INFORMATION

A1. What is the highest level of education that you have received?
No formal	Primary	Junior high	High School	University	Graduate
education		school	(vocational)	(vocational)	(junior college) school
___00 		___01	___07		___10		___13		___17
Illiterate		1st grade	1st yr		1st yr high	1st yr uni-
___90		___02	___08		school/junior	versity/4th yr
Literate		2nd grade	2nd yr		college		junior college
			___03	___09		___11		___14
			3rd grade	3rd yr		2nd yr high	2nd yr uni-
			___04	(senior		school/junior	versity/5th yr
			4th grade	level in		college		junior college
			___05	Japanese		___12		___15
			5th grade	education)	3rd yr high	3rd yr
			___06				school/junior	university
			6th grade				college		___16
			(junior 							4th yr
			level in 							university		
			Japanese
			educa-
			tion)	

A2. Are you Taiwanese, Hakka, mainlander?  Or, what is your nationality?
	___1 Taiwanese					___3 Mainlander
	___2 Hakka						___4 Aboriginal
	___5 Other:____________________

A3. What is your current marital status?
	___1 Married						___4 (Formally) separated
	___2 Never married				___5 Widowed
	___3 Divorced						___6 Living with a companion

A4. What is the current monthly income of your household?
	___1 NT$19,999 or less			___4 NT$60,000-79,999
	___2 NT$20,000-39,999			___5 NT$80,000-99,999
	___3 NT$40,000-59,999			___6 NT$100,000 or above

B. 	CONDITIONS SURROUNDING FALL

B1. Sometimes elderly persons will fall.  They may fall while trying to stand up, sit down, get into bed or while walking.  In the past year, have you had a fall?
		___1 Yes			___2 No (Skip to C4.3)

C. 	BACKGROUND INFORMATION REGARDING FALL

C1. In the past year, how many times have you fallen?  
No. of times: ______________

C1.1 How many of the falls occurred while at home? How many of the falls occurred while outside the home?  
		No. of falls at home: _______________
		No. of falls outside the home: _______________

C2. I would like to ask you to recall the fall that you remember most clearly.

	C2.1 Why do you remember that fall?
		___1 First fall				___2 Seriously injured
		___3 Retold to the respondent by family member(s)
		___4 Other, please specify: _______________

C3. What was the date and time of that fall?
_____ Y _____ M _____ D			Time: ______________

(※ATTENTION: If the date given by the respondent is more than one year from the date of interview, please treat this as a case of “no falls within the past year,” and skip to C4.3.)

	C3.1 What was the weather like at that time?
		___1 Clear			___2 Overcast			___3 Rainy
		___4 Don’t know

C4. Where did that fall occur?  In your home, or outside your home?
	___ 1 Outside the home		___2 Inside the home (Skip to C4.2)

C4.1 Where outside the home?
		___1 On the street				___6 On a bus or at a bus stop
		___2 In a hilly/mountainous area	___7 At a hospital or elderly center
		___3 In the field/on a farm		___8 In a public place (e.g. theater,
		___4 At a park						 department store, etc.)
		___5 In the suburbs				___9 Other, please explain:
										 _________________
		(After the respondent has answered this question, please skip to C4.3)
	
C4.2 Where in the home?
		___01 Living room				___07 Stairs
		___02 Dining room				___08 Lavatory (outhouse)
		___03 Bathroom				___09 Courtyard/patio/yard
		___04 Bedroom				___10 In front of the altar (for
		___05 Kitchen					      worshipping)
		___06 Balcony				___11 Other, please specify:
										  _______________

C4.3 Evaluate the safety of the respondent’s home, using the Elderly Household Safety Evaluation Form below.

ELDERLY HOUSEHOLD SAFETY EVALUATION FORM

(Mark N/A for the following situations: the residence does not have the mentioned facility, or has the mentioned facility but the respondent does not use it.)

TOPIC		DESCRIPTION					  YES	   NO		N/A
I. 	Overall	1.Inadequate partitions, ceiling is too  
environment	  low							   1 		 0		 8
of the home	2.Hard flooring (e.g. marble, porcelain
(including		tile, terrazzo, linoleum) with no soft
living room)	  surface (e.g. safety tiles, carpet, etc.)    1		 0		 8
and dining	3.Floor is uneven, or has obvious bulges
room)		  or damaged areas				   1		 0		 8
 4.There are toys, small objects such as
			  batteries, buttons, erasers, coins, etc.
			  scattered on the floor or chairs		   1		 0		 8
5.	The floor is usually dry and not
  slippery						   1		 0		 8
6.	The furniture in the living room and
 bedroom (sofa, table, chairs) or dining
 room table or counters has sharp edges/
 corners or is broken or unstable		   1		 0		 8
7.	There are no protective covers for the
 electric sockets					   1		 0		 8
8.	There are wires or cords running along
 the floor					           1		 0		 8
9.	The rug or carpet is not fixed, slides
 easily 							   1		 0		 8
10.	The lighting is inadequate			   1		 0		 8
11.	Entrances to the living room,dining 
 room, bedroom have a high doorsill, 
   are narrow or blocked with boxes	   1		 0		 8

ELDERLY HOUSEHOLD SAFETY EVALUATION FORM (CONTINUED)

(Mark N/A for the following situations: the residence does not have the mentioned facility, or has the mentioned facility but the respondent does not use it.)

TOPIC		DESCRIPTION					  YES	   NO	   N/A
II.	Bathroom/	1.Hairdryer is located in a place that is
Lavatory		  not easy to reach, always plugged in	   1		 0		 8
(Outhouse)	2.The hotwater heater is inside, or is
			  outside in an unventilated area		   1		 0		 8
3.	There is no mat outside the bathroom
 door to prevent slipping			   1		 0		 8
4.	The bathtub is slippery and there are 
 no handrails						   1		 0		 8
5.	The bathroom is unventilated		   1		 0		 8
6.	Once the bathroom door is locked from
 the inside, it cannot be opened from the
 outside							   1		 0		 8
7.	The hot water pipes are exposed		   1		 0		 8
8.	There are no handrails next to toilet	   1		 0		 8
9.	The toilet is squat-style			   1		 0		 8
10.	The bathroom is not near the
   bedroom, or is outside the home	   1		 0		 8

III. 	Bedroom	1. The bed is too high or too low		   1		 0		 8
2.	The bed does not have guardrails or
 handrails						       1		 0		 8

IV. 	Kitchen	1. The floor is oily					   1		 0		 8
2.There is no fan for removing smoke
  during cooking					       1		 0		 8
3.Cooking utensils are scattered		       1		 0		 8

ELDERLY HOUSEHOLD SAFETY EVALUATION FORM (CONTINUED)

(Mark N/A for the following situations: the residence does not have the mentioned facility, or has the mentioned facility but the respondent does not use it.)

TOPIC		DESCRIPTION					YES	    NO		N/A
V. 	Balcony/ 1. There are objects scattered on the 
Stairs	 balcony or stairs, such as batteries,
 buttons, nails, empty plastic bags,
 rope, etc.						    1		 0		 8
2.The balcony does not have railings.
 Or, the balcony has railings, but they
 are lower than waist level, or the 
 distance between railings is larger than
 shoulder width.  Or, the railings are
 broken or loose					    1		 0		 8
3.The stairs have handrails that are easy
  to grasp onto					    1		 0		 8
4.Some of the steps are damaged	  	    1		 0		 8
5.The stairs are too narrow, or the 
  distance between steps is too great,
  or the steps are uneven			        1		 0		 8
6.The stairs have appliques to prevent
  slipping.  Or, the edges of the steps
  have non-skid strips				    1		 0		 8
7.There are objects in the stairway, 
  such as damaged furniture that is
  waiting to be fixed, etc.			    1		0		 8
8.The lighting in the stairway is poor
  or there is no lighting (including
  emergency lighting and fluorescent
  lights)							   1		 0		 8
9.The stairs lead directly to the entrance
  of a room, and the room’s door opens
  towards the stairs					   1		 0		 8

ELDERLY HOUSEHOLD SAFETY EVALUATION FORM (CONTINUED)

(Mark N/A for the following situations: the residence does not have the mentioned facility, or has the mentioned facility but the respondent does not use it.)

TOPIC		DESCRIPTION					  YES	    NO		N/A
VI. 	Patio/	1.The ground is cement	  	  		   1		 0		 8
			2.The ground is uneven, or there are
			  obvious bulges or sunken areas		   1		 0		 8
3.Water drainage is inadequate. There
         is often water on the ground		           1		 0		 8
4.There are miscellaneous objects lying 
         around, the area is generally untidy	       1		 0		 8
5.	There are chickens, ducks, pigs and/
         or other animals roaming around	           1		 0		 8

VII. 	In front 	1.The lighting is dim or inadequate	       1		 0		 8
of the altar	2.The flooring is hard material and
         there are no mats to prevent slipping	       1		 0		 8
3.The table for the spirit tablet or the 
			  switch for the flourescent light is too
			  high, must stand on a chair to reach
			  incense holder, turn on the light or
			  place food offerings	  			   1		 0		 8
4.The altar is on the balcony, stairs or
			  in a corner						   1		 0		 8
  5.There are candles, ashes from 
			incense or other miscellaneous objects     1		 0		 8

ELDERLY HOUSEHOLD SAFETY EVALUATION FORM (CONTINUED)

(Mark N/A for the following situations: the residence does not have the mentioned facility, or has the mentioned facility but the respondent does not use it.)

TOPIC		DESCRIPTION					  YES	   NO		N/A
VIII. 	Other	1.The floor on either side of the door
       threshold is uneven, and there are no
       mats to prevent slipping			           1		 0		 8
2.Some things that need to be used often
       are not easy to reach, such as too high
       or too low						           1		 0		 8
3.The main caregiver does not live very
       close by (lives more than 1 house away)         1		 0		 8
4. In places where the elderly is most likely
  to be alone, such as the bathroom and 
  bedroom, there are no bells, pagers or
  attention devices					    1		 0		 8
5. Emergency services numbers are not
  listed next to the telephone			    1		 0		 8
6. The home does not have a first-aid kit	        1		 0		 8
7. The home does not have an air-
 			 conditioning system				    1		 0		 8
   8. Physical aids, walker or wheelchair are
 inadequate or inappropriate			    1		 0		 8
   9. Shoes are ill-fitting, too big or too 
 small, or have no traction			    1		 0		 8

※	For respondents, who have not had a fall during the past year, skip to C6.1.

C4.3a. (Do not ask those respondents who have not had a fall in the past year.)  After that fall, were there any changes in the facilities of your home (repairs, installation or additions)?
	___1 Yes			___2 No

C4.3b. Why were changes made? Please explain: _________________________

C4.3c. Please list what changes were made: __________________________
 (use C4.3 categories)

C4.3d. Who suggested the changes or did you suggest them? ______________
 (Use the code numbers from question D16.)

C4.3e. How do you feel about the changes? (Plural answers may be given.)
		___a Provide more convenience		___b Are of no help
		___c Provide a feeling of security		___d Not used to them
		___e Other, please explain:_____________________________

C5. What were you doing at the time you fell down?

	C5.1 For falls at home:
		___01 Watching TV or brewing tea	___02 Eating
		___03 Taking a bath/shower			___04 Getting in or out of bed
		___05 Cooking					___06 Hanging up clothes to dry
		___07 Going up or down stairs		___08 Going to the bathroom
		___09 Drying rice					___10 Worshipping
		___11 Getting up from or sitting down	___12 Walking around
			  in a chair		
		___13 Putting on clothes				___14 Washing clothes
		___15 Stepping over a doorsill		___16 Washing dishes
		___17 Standing up or turning suddenly	___18 Reaching for something in
											  a high place
		___19 Other, please explain: ________________________________

	(Continue on to C6)

	C5.2 For falls outside of the home:
		___1 Shopping					___2 Working in the fields
		___3 Going for a walk				___4 Sightseeing
		___5 Riding a (specify, if: bicycle, motorcycle, scooter, etc.)
		___6 Riding in a vehicle, or getting in or out of a vehicle
		___7 Shopping at a department store, watching a play or movie, etc.
		___8 Going to the bathroom, walking around, etc.
		___9 Other, please explain: ________________________________

C6. Before that fall did you have any of the following conditions?
C6.1 Do you have any of the following conditions now?
	(Inquire about each of the conditions.)

							      C6				C6.1
1. 	Lightheadedness, Dizziness, 
   Drowsiness				___1 Yes ___2 No	___1 Yes ___2 No
2. 	Heart palpitations, Chest  
  pains						___1 Yes ___2 No	___1 Yes ___2 No
3. 	Shortness of breath			___1 Yes ___2 No	___1 Yes ___2 No
4. 	Paralysis on one side of the
  body, Slurred speech		    ___1 Yes ___2 No	___1 Yes ___2 No
5. 	Weakness in the legs		___1 Yes ___2 No	___1 Yes ___2 No
6. 	Loss of consciousness		___1 Yes ___2 No	___1 Yes ___2 No
7. 	Bladder or bowel incontinence___1 Yes ___2 No	___1 Yes ___2 No
8. 	Eyesight is dim, Blind, Sees 
  stars or flashes of light		___1 Yes ___2 No	___1 Yes ___2 No
9. 	Spasms, Paralysis			___1 Yes	___2 No	___1 Yes ___2 No
10. 	Other, please specify:
_____________________	  ___1 Yes	___2 No	___1 Yes ___2 No

(For those respondents who have not had a fall during the past one year, skip to D12.1)

C7. After you fell, how long were you on the ground, before you stood up again?
	___1 Less than 10 minutes		___2 10-30 minutes
	___3 More than 30 minutes		___4 Don’t know

C8. When you fell down, was there anyone with you?
	___1 Yes			___2 No			___3 Don’t know

C9. After you fell, did you try to stand up, but were unable to?
	___1 Yes			___2 No			___3 Didn’t try to stand up

C10. How did you feel when you fell? (Plural answers may be given.)
	___a Startled			___b Scared
	___c Wanted to cry		___d Dizzy
	___e Unlucky			___f In pain
	___g Other, please explain:______________________________

C11. After you fell down, did you seek help?
	___1 Yes			___2 No (Skip to C12)

	C11.1 How did you seek help? (Plural answers may be given.)
		___a Called out loudly		
___b Telephoned a relative
		___c Telephoned 119 (the number for emergency services)
		___d Stood up by his/herself
		___e Other, please explain:_____________________________

C12. Since that fall, when you are walking, are you afraid that you will fall again?
	___1 Yes				___2 No 

D. 	HOSPITALIZATION AND RECOVERY

(1) 	Emergency medical care before seeking treatment:

D1. At the time you fell and were injured, did anyone give you emergency care?
	___1 Yes				___2 No (Skip to D2)

	D1.1 What kind of emergency care? (Plural answers may be given)
		___a Stop bleeding, hemorrhage	___b. Apply ice
		___c Stabilize condition			___d Dress wound(s)
		___e. Other, please explain:_________________________

D2. Were you sent for treatment immediately after your fall (i.e. within 2 hours)?
	___1 Yes				___2 No (Skip to D2.2)

	D2.1 Who sent you?
		___1 Relative, friend or neighbor	___2 Ambulance (emergency services) 
		___3 Private ambulance company	___4 Taxi
		___5 Passerby					___6 Other, please explain: _______
	(Skip to D2.3)

	D2.2 Why didn’t you receive medical care immediately?
		___1 Didn’t feel any pain or uncomfortableness
		___2 Felt a little pain, but could tolerate it
		___3 Didn’t think emergency care was necessary
		___4 Unclear, unconscious, was not immediately discovered by anyone
		___5 Other, explain: ______________________________

	(Skip to D2.4)

D2.3 By your estimate, how much did you spend to be sent for medical care (including transportation fees)?  How much time did it take for you to be sent from where you fell to where you received medical care?
			NT$___________________________

			__________hours _________ minutes

	D2.4 How long after your fall did you seek treatment?  How much money did
     you spend for that treatment?
		_________years __________ months _________ days

		NT$_____________________________________________

D3. Did you go to an emergency room?
	___1 Yes (Skip to D4)		___2 No

	D3.a Did you go to a clinic or outpatient department?
		___1 Yes (Skip to D5)		___2 No (Skip to D12)

D4. What kind of emergency room were you sent to (clinic, hospital, or other)?
	Please explain: __________________________
	Name of clinic/hospital:__________________________

	D4.1 From where you fell, how long does it take to reach that emergency room?
		_________________________ minutes

	D4.2 How long did you stay in the emergency room?
		___1 Less than one hour		___2 1-6 hours
		___3 More than 6 hours, but less than 12 hours
		___4 12-24 hours
		___5 More than 24 hours

D5. After examining you, how did the doctor describe your condition? (Ask the following.)

	D5.1 Did you have any head or neck injuries?
		___1 Yes			___2 No (Skip to D5.2)

___1 Slight injury—Outer head injury combined with headache, dizziness, blurred vision, but conscious and clear 
___2 Moderate injury—Outer head injury, with short-term loss of consciousness, skull fracture
___3 Serious injury—Outer head injury, loss of consciousness (for more than 15  minutes) or short-term amnesia (for less than 3 hours); but no serious abnormalities on neurological exam; cervical vertebrae fracture, but no nerve damage
___4 Life threatening injury—Outer head injury, loss of consciousness (for more than 15 minutes) combined with neurological abnormalities; amnesia for 3-12 hours, complex skull fracture
___5 Near fatal injury—Outer head injury, loss of consciousness (for more than 24 hours), amnesia (for more than 12 hours); cerebral hemorrhage, increased cerebral pressure (incapable of clear thinking, heart rate less than 60 beats per minute, pupils dilated); cervical vertebrae fracture, quadriplegic (paralysis below the neck); labored respiration

D5.2 Did you have any injuries to your face (including eyes, nose, ears, mouth)?
	___1 Yes			___2 No (Skip to D5.3)

___1 Slight injury—Eye injury (eyelid, conjunctiva, cornea), damage or retinal hemorrhage; superficial puncture wound, surface wound, ear canal damage, internal ear or middle ear damage, or eardrum injury, broken tooth (teeth), gum damage, superficial tongue wound

___2 Moderate injury—Puncture wound less than 5 x 5cm, or depth of wound less than 10cm; some nerve damage, eyeball damage, detachment of the retina, deep or large tongue wound, damage in the mouth cavity, broken facial bone
___3 Serious injury—Damaged artery, occipital bone fracture, jawbone or facial bone fracture, but less than 20% blood loss (less than 5000cc)
___4 Life threatening injury—20% blood loss (5,000cc or more); jawbone or facial bone fracture
___5 Near fatal injury

D5.3 Did you have any injuries to your chest?
	___1 Yes			___2 No (Skip to D5.4)

___1 Slight injury—Chest muscle pain or tightness
___2 Moderate injury—Simple rib fracture or breastbone fracture; chest injury
___3 Serious injury—Multiple rib fractures; hemothorax or pneumothorax; diaphragm damage; lung injury
___4 Life threatening injury—Open chest wound; flail chest; air in the mediastinum; myocardial injury; pericardial injury
___5 Near fatal injury—Impaired respiration (respiratory tract damage or bleeding into the mediastinum cavity, etc.); damage to the aorta, myocardium or chest combined with impaired blood circulation

D5.4 Did you have any injuries to the abdominal region?
	___1 Yes			___2 No (Skip to D5.5)

___1 Slight injury—Abdominal muscle pain or minor abdominal injury
___2 Moderate injury—Abdominal wall contusion
___3 Serious injury—Injury to the abdominal cavity organs; bladder injury; internal bleeding; ureter contusion; damaged urethra; thoracic and/or lumbar vertebrae fracture with no neurological damage
___4 Life threatening injury—Internal abdominal injuries (including injury to the spleen, pancreas, and/or kidneys); bladder injury; reproductive organ injury; thoracic and/or lumbar vertebrae fracture with limb paralysis
___5 Near fatal injury—Serious injury to the abdominal cavity organs or blood vessels (not including spleen, kidney, ureter, etc.)

D5.5 Did you have any limb (arm, leg) injuries?
	___1 Yes			___2 No (Skip to D5.6)

___1 Slight injury—Minor dislocation; dislocated or fractured finger (toe)
___2 Moderate injury—Complex fracture of the finger; serious dislocation of a major joint
___3 Serious injury—Dislocation of a long bone or multiple fractures of the hand (foot); single complex fracture of a long bone; multiple bone fractures; major joint dislocation; finger(s) (toe(s)) amputated; major blood vessel or nerve damage
___4 Life threatening injury—Amputated limb
___5 Near fatal injury—All four limbs with complex fractures

D5.6 Did you have any skin injuries?
	___1 Yes		___2 No (Skip to D6)

___1 Slight injury—Pain all over the body; minor wound, contusion or scratch; first degree burns or second/third degree burns covering a small area
___2 Moderate injury—Larger wound (less than 7.6cm wide), contusion or scratch; second/third degree burns covering 10-20% of the body
___3 Serious injury—Very large wound (more than 7.6cm wide), contusion or scratch; second/third degree burns covering 20-30% of the body
___4 Life threatening injury—Serious wound combined with large blood loss; second/third degree burns covering 30-50% of the body
___5 Near fatal injury—Second/third degree burns covering more than 50% of the body

D6. Were you hospitalized?		___1 Yes		___2 No (Skip to D11)

D7. During that hospitalization, who was the person who mostly took care of you?
	_______________ (Enter a code number from D16)

D8. During that hospitalization, did you undergo surgery?
	___1 Yes			___2 No

D9. During that hospitalization, did you receive physical therapy/rehabilitation therapy?
	___1 Yes			___2 No

D10. How long was that hospital stay? ____________ days

D11. After that fall, from how many places did you receive treatment (such as emergency room, clinic, hospital (hospitalization), physical therapy/rehabilitation, etc.)?
	No. of places: ________ (including Chinese medicine hospital, Western medicine hospital, clinic, pharmacy, clinic for setting broken bones, Chinese martial/healing arts center)

	In total how much money did you spend?  NT$_____________
	(Do not include amount paid by NHIP (National Health Insurance Program).  Only include what the respondent paid out of his/her own pocket.)

	D11.1 Did the amount that you paid for treatment cause any financial hardship?
		___1 No hardship		___2 A little hardship
		___3 Some hardship	___4 A lot of hardship

D12. DISORDER/ILLNESS FORM

DESCRIPTION OF		D12. Before that fall	D12.1 Do you currently have
ILLNESS OR				did you have this		this illness or disorder?
DISORDER				illness or disorder?		
1. 	High blood pressure		___1 Yes ___2 No		___1 Yes ___2 No
2. 	Diabetes				___1 Yes ___2 No		___1 Yes ___2 No
3. 	Heart disease			___1 Yes ___2 No		___1 Yes ___2 No
4. 	Stroke (cerebral 
  hemorrhage)			___1 Yes ___2 No		___1 Yes ___2 No
5. 	Cancer				___1 Yes ___2 No		___1 Yes ___2 No
6. 	Bronchitis, respiratory
  tract infection or other
  respiratory disorder		___1 Yes ___2 No		___1 Yes ___2 No
7. 	Dislocation, sprain		___1 Yes ___2 No		___1 Yes ___2 No
8. 	Arthritis or rheumatism	___1 Yes ___2 No		___1 Yes ___2 No
9. 	Chronic back pain		___1 Yes ___2 No		___1 Yes ___2 No
10. 	Liver, gall bladder
  disease				    ___1 Yes ___2 No		___1 Yes ___2 No
11. 	Bone fracture, which	
bone? (Plural answers	
may be given.)
11.1 	Upper appendage	___1 Yes ___2 No		___1 Yes ___2 No
11.2 	Lower appendage	___1 Yes ___2 No		___1 Yes ___2 No
11.3 	Other (specify:)	_______________		_______________
12. 	Cataract(s)			___1 Yes ___2 No		___1 Yes ___2 No
13. 	Glaucoma			 	___1 Yes ___2 No		___1 Yes ___2 No
14. 	Detached retina		___1 Yes ___2 No		___1 Yes ___2 No
15. 	Parkinson’s disease		___1 Yes ___2 No		___1 Yes ___2 No
16. 	Senile dementia		___1 Yes ___2 No		___1 Yes ___2 No
17. 	Anemia				___1 Yes ___2 No		___1 Yes ___2 No
18. 	Varicose veins or other
  leg blood vessel disorder	___1 Yes ___2 No		___1 Yes ___2 No
19. 	Gastrointestinal ulcer or
  gastrointestinal tract
  bleeding				___1 Yes ___2 No		___1 Yes ___2 No
20. 	Kidney disease			___1 Yes ___2 No		___1 Yes ___2 No
21. 	Thyroid disorder		___1 Yes ___2 No		___1 Yes ___2 No
22. 	Gout					___1 Yes ___2 No		___1 Yes ___2 No
23. 	Tuberculosis			___1 Yes ___2 No		___1 Yes ___2 No
24. 	Bedsores, skin ulcers,
  serious burns, or other
  skin disorders			___1 Yes ___2 No		___1 Yes ___2 No
25. 	Urinary incontinence	___1 Yes ___2 No		___1 Yes ___2 No
26. 	(Do not ask female 
  respondents)
  Prostate trouble		    ___1 Yes ___2 No		___1 Yes ___2 No
27. 	Other (explain):		_______________		_______________

D13. What is your current living arrangement?
	___1 Lives in one place
	___2 Lives mostly in one place, but occassionally visits other people for a short 
time (less than one month)
	___3 Rotates between two places (stays for at least 3 months each time)
	___4 Rotates among many places (stays for at least 1 month each time)
	___5 No stable arrangement
	___6 Other, please specify: __________________________________________

	D13.1 Has your living arrangement changed in the past year?
		___1 Yes			___2 No (Skip to D14)

	D13.2 How has it changed? 
		Please explain: _____________________________________

	D13.3 When did it change?
		_____ Y _____ M _____ D

D14. Currently, who usually lives together with you?
	_______________ (Use code numbers from D16)

	D14.1 In the past year, has anyone moved in or out of your household?
		___1 Yes			___2 No (Skip to D15)

	D14.2 Who moved in and/or out?
		Please explain: ___________________________________________

	D14.3 When did the change(s) occur?
		_____ Y _____ M _____ D

D15. In your home, are there preschoolers or elementary school aged children playing around you when you are moving about?
	___1 No		___2 Rarely	___3 Sometimes	___4 Often

D15.1 (Do not ask respondents who have not had a fall in the past year)
		  Before that fall, were there preschoolers or elementary school aged 
		  children playing around you at home?
			___1 No		___2 Rarely	___3 Sometimes	___4 Often

D16. In the past year, who have you depended on most for care at home?
	________________ (Use the code numbers below)

D16.1 (Do not ask those respondents who have not had a fall in the past year.) Before that fall, was he/she taking care of you?
	___ No		___1 Yes (Skip to D17)

	D16.1a Who was taking care of you at that time?
			_____________ (Use the code numbers below.)

Table D16:
01 Spouse					10 Sister
02 Son							11 Husband’s parent
03 Daughter-in-law			12 Wife’s parent
04 Daughter					13 Grandson’s wife
05 Son-in-law					14 Granddaughter’s husband
06 Grandson					15 Other relative
07 Granddaughter				16 Friend
08 Parent					17 Home care nurse or hired caregiver
09 Brother					18 Self
19 Other __________________

D17. At home does anyone give you advice on how to prevent falls? (If yes, ask): Does he/she often give you advice or sometimes or rarely?
	___0 No(Skip to D18)		___1 Rarely (Skip to D18)
	___2 Sometimes			___3 Often

D17.1 (Do not ask those respondents who have not had a fall in the past year.) Before that fall, did he/she give you advice on how to prevent a fall? (If yes, ask): Did he/she often give you advice, or sometimes or rarely?
	___0 No	___1 Rarely	___2 Sometimes	___3 Often

D18. Do you often need to get up in the middle of the night to urinate?
	___1 Yes			___2 No (Skip to D19)

D18.1 (Do not ask those respondents who have not had a fall in the past year.) Before that fall, did you often get up in the middle of the night to use the bathroom?
	___1 Yes			___2 No

D19. Do your family members (or nurse/caregiver) often encourage you to move around independently, or exceed your physical abilities?
	___1 Yes			___2 No (Skip to Section E)

D19.1 (Do not ask those respondents who have not had a fall in the past year.) Before that fall, did your family members (or nurse/caregiver) often encourage you to move around independently, or exceed your physical abilities?
	___1 Yes			___2 No

E. 	KNOWLEDGE AND ATTITUDE ABOUT PREVENTING FALLS

E1. (Before that fall) Did you worry about falling down and getting injured?
	___1 Never (didn’t think about it)		___2 Rarely
	___3 Sometimes					___4 Often

E2. (Before that fall) Did you know how to reduce the risk of falls at home?
	___1 Yes			___2 No (Skip to E3)

E2.1 Please tell me some measures that can be taken at home to reduce the risk of falls.
(1)	Overall facilities 	___1 Don’t know	___2 Mentioned 1-2 measures
(including dining 	  ___3 Mentioned 3 or more measures
room, living room)
(2)	Bathroom, 		___1 Don’t know	___2 Mentioned 1-2 measures
Outhouse			___3 Mentioned 3 or more measures
(3)	Bedroom			___1 Don’t know	___2 Mentioned 1-2 measures
  ___3 Mentioned 3 or more measures
(4)	Kitchen			___1 Don’t know	___2 Mentioned 1-2 measures
  ___3 Mentioned 3 or more measures
(5)	Balcony, Stairs		___1 Don’t know	___2 Mentioned 1-2 measures
  ___3 Mentioned 3 or more measures
(6)	Courtyard, Yard	___1 Don’t know	___2 Mentioned 1-2 measures
  ___3 Mentioned 3 or more measures
(7)	In front of the altar	___1 Don’t know	___2 Mentioned 1-2 measures
  ___3 Mentioned 3 or more measures
(8)	Other				___1 Don’t know	___2 Mentioned 1-2 measures
  ___3 Mentioned 3 or more measures

E3. (Before that fall) Did you ever think about how you would seek help if you were injured in a fall?
	___1 Never		___2 Rarely		___3 Sometimes	___4 Often

E4. (Before that fall) Did you ever think about where you should be sent for treatment if you were injured in a fall?
	___1 Never		___2 Rarely		___3 Sometimes	___4 Often

E4.1 In your mind, where did you want to be sent for treatment?
		Name of hospital/clinic:_____________________________
		(Continue on to E4.2)

※	For those respondents who answered D3, after falling were not sent to an emergency room, do not ask E4.2-E4.2b.
E4.2 How long does it take from your home to a hospital?
_____ hours _____ minutes

		E4.2a Is that the same place, mentioned in D4?
			___2 No			___1 Yes (Skip to E4.2c)

		E4.2b Why were you sent to a different place?
				____________________________

		E4.2c Are the times reported in D4.1 and E4.2 the same?
			___2 No			___1 Yes (Skip to E5)

		E4.2d Why are the times different?
				_____________________________

E5. Are you often at home alone for more than one hour at a time?
	___1 No or rarely (less than once per week)
	___2 Sometimes (2-3 times per week)
	___3 Often (4 or more times per week)

E6. Does anyone ask you how you are or pay attention to your health status?
	___1 Less than once per day		___2 Once a day
	___3 Twice or more per day

F. 	DAILY LIFE ACTIVITIES

F1a. If there is none to help you, or no aids, do you have difficulty performing any of the following activities on your own?
F1b. How long have you had this difficulty?
F1c. Do you think that you can recover this ability? (If incapacitated for more than three months, do not ask this question.)
F1d. Do you use any physical aids/equipment?
F1e. Is there anyone who helps you with your daily life activities?
_____________________________________________________________________
ACTI-	F1a.			F1b.			F1c.			F1d.			F1e.
VITY	Any difficulty	How long 	Able to 		Use any aids?	Does anyone			performing	have you had	recover?		If answered	help you to 
		this activity?	this difficulty?	(If incapaci-	yes, choose	do this activity?
		*”0”-go to 				tated for 		the code 		
		 next item 				more than	number from	
		*”1”or “2”-				3 months,	Form F1
		ask F1b-F1e				don’t ask)
		*”3”-F1b- 	
F1c, then go	 
		to next item
		0 No difficulty	0 Less than 3	0 No		  00 No		0 No
		1 Need an aid,	 months		1 Yes		Code No.		1 Someone
		 but can do it	1 3-6 months							 supervises
		2 Need help	2 6 months-							2 Someone
		3 Cannot do	  1 year							 helps
		 it at all		3 1-5 years
					4 More than 5
					  years
1 Eat
2 Get in/out of bed
3 Sit down in/get up from a chair
4 Walk around the house
5 Walk around outside the house
6 Get dressed
7 Bathe
8 Use the toilet
9 Urinary/bowel continence

F1. SPECIAL AID CODE NUMBERS

F1d1. 	01 Special bowl/chopsticks		02 Special rehabilitation equipment
		03 Other: ___________________________________
F1d2.	01 Wheelchair					02 Crutches
		03 Handrails					04 Cane
		05 Walker					06 Other: ________________
F1d3.	01 Crutches					02 Handrails
		03 Cane						04 Walker
		05 Other:_____________________________
F1d4. 	01 Wheelchair					02 Crutches
		03 Handrails					04 Cane
		05 Walker					06 Leg or back brace
		07 Prosthesis/artificial limb		08 Chair or ladder that can be 
									   raised or lowered
		09 Other:___________________________________
F1d5.	01 Seeing eye dog				02 Walker
		03 Wheelchair					04 Cane
		05 Orthopedic/corrective shoes	06 Leg or back brace
		07 Prosthesis/artificial limb		08 Ramp
		09 Handrails					10 Respirator
		11 Crutches					12 Other:____________________
F1d6. 	01 Custom made clothing		02 Special rehabilitation equipment
		03 Other: ________________________
F1d7. 	01 Bath chair					02 Handrails
		03 Hand-held shower head		04 Crutches
		05 Rubber mat					06 Other:____________________
F1d8.	01 Toilet that can be raised or 	02 Bedpan
		   lowered					
		03 Handrails					04 Urinal
		05 Adult diapers				06 Paper underwear
		07 Urine bag					08 Other:_____________________
F1d9.	01 Adult diapers				02 Paper underwear
		03 Urine bag					04 Other:_____________________

F2. OTHER DAILY LIFE ACTIVITIES

F2a. Do you usually do any of the following activities?
F2b. Do you have difficulty performing any of these activities on your own?
F2c. Is the difficulty caused by a health problem, failing physical ability or senility?
F2d. How long have you had this difficulty?
F2e. Do you think that you can recover this ability?
F2f. Does anyone help you to perform any of the following activities?

ACTI-	F2a.			F2b.		F2c.			F2d.			F2e.		F2f.
VITY	Do you 		Do you 	Is the difficultyHow long	Do you	Does any-		usually do	have any	due to a health	have you had	think that	one help
		this activity?	difficulty	problem, fail-	this difficulty?	you can	you to do
		*”0”-Go to	doing this	ing physical				recover	this acti-
		 next item	activity?	ability or senil-			this abil-	vity?
					*”0”-Go	ity?						Ity?
					to next							(If inca-
					item								pacitated	
					*”1”,”2”							for more
					Ask F2c-							than 3
					F2f, then							months, 
					go to 							do not
					next item							ask)
		0 Yes		0 No 	0 No		  0 Less than	0 No	  0 No
		1 No		  difficulty	1 Yes		 3 months	  1 Yes	1 Yes
					1 Needs				1 3-6 months
					help					2 6 months-
					2 Cannot 				  1 year
					do it at all				3 1-5 years
						`				4 More than
										  5 years
1 Light housework (e.g. straightening up the living room, washing dishes, etc.)
2 Washing clothes
3 Cooking
4 Buying everyday use items
5 Managing finances (performing calculations, paying bills)
6 Taking medicine (Go directly to F2b)
7 Making telephone calls  (Go directly to F2b)

F3. USE OF MEDICINE

(F3d. Only ask those respondents who have had a fall within the past one year.)
TYPE	F3a.				F3b.				F3c.			F3d.
OF		Have you used this	Did a doctor		How often do	Before that fall,
MEDI-	kind of medicine in	prescribe it to you	you take it?	did you take this
CINE	the past month?	or did you buy it	*If answered	kind of medicine?
		*”0”-Go to the	from a pharmacy?	“1” to F3a, 	*Do not ask those
		next line							do not ask.	respondents who
													have not had a fall.
		0 No			1 Prescribed by 	1 Every day	0 No
		1 Only when 		a doctor			2 At least once	1 Only when needed
		needed			2 Bought from a	a week		2 Often or regularly
		2 Often or regularly	pharmacy			3 Less than 	
						3 Both			once a week
a. 	Pain medication (Analgesic)
b.	Anti-hypertensive medication
c. 	Heart medication
d. 	Cold medication
e. 	Medication for promoting blood circulation
f. 	Medication to treat diabetes or insulin injections
g. 	Gastrointestinal tract medication
h. 	Sleeping pills or sedatives
i. 	Restorative supplements (including Chinese herbal medicine)
j. 	Vitamins
k. 	Liver medication
l. 	Calcium
m. 	Laxatives
n. 	Anti-inflammatory (medication for treating arthritis)
o. 	Alcohol/Liquor
p. 	Other, please explain:________________________________

F4. Everyone has mood swings.  In the past week, have you had any of the following feelings or met any of the following situations? (If yes, ask):Do you rarely meet this situation, or sometimes or often? (Are you like this four or more days of the week, or 2-3 days per week, or only one day per week?)
During the			0 No					Yes
past week, 					1 Rarely		2 Sometimes		3 Often
have you…					(only one day)	(2-3 days)		(4 or more 
														days)
(1) 	felt like not eating or that your appetite was not good
(2) 	felt that everything requires a lot of effort
(3) 	not slept well
(4) 	been in a bad mood
(5) 	felt lonely
(6) 	felt that the people around you are unfriendly, hard to get along with
(7) 	felt that the people around you don’t like you
(8) 	felt heartbroken
(9) 	felt that you have no energy to do anything
(10) 	felt happy
(11) 	felt that your life is good

F5. SELF-RATED HEALTH STATUS

	F5.1 How would you rate your current health status?
		___1 Excellent			___2 Good			___3 Average
		___4 Fair				___5 Poor
	
F5.2 Do you feel that your health is better, about the same or worse than most people your age?
	___1 Better		___2 About the same		___3 Worse

F5.3 Compared to last year at this time, do you feel that your health now is better, about the same or worse?
	___1 Better		___2 About the same		___3 Worse

F5.4 In general, are you satisfied with the condition of your health?
	___1 Very satisfied		___2 Satisfied			___3 Average
	___4 Dissatisfied			___5 Very dissatisfied

F6. MEMORY TESTING
(INTERVIEWER: Please say the following to the respondent):
(I would like to ask you some questions to test your memory.  Even people who have an excellent memory will forget some things, so please relax.)
1 Correct		2 Incorrect
___			___			F6.1 Please tell me your address ________________
(If the respondent can clearly remember any one of the following: county/city, village/town, or street, mark “correct.”)
(If F6.1 is incorrect, ask F6.2.  Otherwise, skip to F6.3)
___			___			F6.2 Where are you now (e.g.at home, in the park, etc.)?
___			___			F6.3 What is the date today?
							_____ Y _____ M _____ D
(If the respondent uses a calendar to calculate the day,the answer is still correct.)
___			___			F6.4 What day of the week is today?________________
(If the respondent uses a calendar to calculate the day,the answer is still correct.)
___			___			F6.5 What is your mother’s maiden name?
(The respondent must remember on his/her own, to be correct.)
___			___			F6.6Who is the current President? _________________
___			___			F6.7Who was the President before him?_____________
___			___			F6.8 How old are you now? _____________________ 
(If the respondent answers with age, according to lunar calendar, the answer is still correct.)
___			___			F6.9 What is your date of birth?
							_____ Y _____ M _____ D
___			___			F6.10 Finally, I want to ask you to perform some simple
							  calculations.  You have 20 oranges and you      
							  eat 3, how many are left? If you continue  							  to eat 3 at a time, how many are left each time?  						    Please tell me the result of each calculation.
							  (20-3 = ? - 3 = ? - 3 =?)
(Interviewer: Please start writing the answers from A.  Once the answer is 8 or less than 8, stop recording the answers.)

							  _____	_____	_____	_____
							   A	  B		  C		  D
(All four answers must be correct. If one answer is incorrect, stop and ask the question again.)
(End of section.  Go to the next section.)
G. 	HEALTH EVALUTION FORM
G1. Physiological condition: According to your current health situation, can you walk around the community, or are you confined to a chair, wheelchair, or bed? Do you have any difficulty taking a bath, eating, etc. on your own?
	___1 No mobility deficiencies; Mobile and able to take care of self, as well as play many roles, and good at human relations.
	___2 No mobility deficiencies; mobile and able to take care of self.  But, has difficulties outside the community, so number of roles is limited.
	___3 Mobile, can move around the house and neighborhood (near home), but cannot perform heavy physical labor, because not enough strength, and the number of roles is limited, but able to take care of self.  (Housewife or person who has never been employed) can take care of the housework, except for difficult jobs.
	___4 Able to move around the home and take care of light work.  Because of weakness, a little difficult to move around the community (near home), but able to take care of self.  Number of life roles is limited.
	___5 Difficulty moving around the home.  Needs help to go outside the home.  Movement is limited, and can only perform simple tasks.  Able to mostly take care of self, but needs help bathing.  Number of life roles is limited.
	___6 Confined to chair or wheelchair.  Needs help to go outside the home.  Can only complete the simplest of tasks, such as turning off and on the TV.  Can take in food, but is dependent on other people for other daily life activities.  Number of roles is very limited.
	___7 Confined to a bed.  Not able to leave the bed at all.  Has lost all ability to take care of self.  Almost no life roles.
	___8 Unconscious (vegetable)
	MOBILITY			SELF CARE				ROLE
	Com- Home Chair Bed	Inde- Bathing-	Eating + De-	Nor-				Li-
	munity				pen-				  pen- mal				mited
							dent				  dent
1	**	  				**						*
2 	**					*								*	
3 	*					*								*
4 			 **			*								*
5 			 *			      *							**
6 					*				   *						*
7						*						*					*
8

G2. Do you usually feel aches and pains?  If so, what level of pain?
	___1 No pain
	___2 Mild pain	a. Occasionally	b. Often		c. Almost always
	___3 Moderate pain	a. Occasionally	b. Often		c. Almost always
	___4 Severe pain	a. Occasionally	b. Often		c. Almost always
	___5 Extremely severe pain	a. Occasionally	b. Often	c. Almost always

G3. Do you usually feel stress? If so, what level of stress?
	___1 No stress; happy and relaxed most of the time
	___2 Mild stress; happy and relaxed much of the time, but anxious and depressed
 	sometimes
	___3 Moderate stress; anxious and depressed much of the time, but happy and
 		   relaxed sometimes
	___4 Severe stress; anxious and depressed most of the time
	___5 Extreme stress; will try to commit suicide

G4. Presently, do you wear glasses (including reading glasses and contact lenses)?
	___0 No			___1 Yes (Skip to G4.b)

	G4a. Can you see things clearly?
			___1 Very clear	___2 Clear	___3 Average
			___4 Unclear		___5 Very unclear

	G4b. When you wear your glasses (or contact lenses) can you see things clearly?
			___1 Very clear	___2 Clear	___3 Average
			___4 Unclear		___5 Very unclear

G5. Presently, do you use a hearing aid?
	___1 No			___1 Yes (Skip to G5.2)

	G5.1 Can you hear clearly?
			___1 Very clear	___2 Clear	___3 Average
			___4 Unclear		___5 Very unclear

	G5.2 When you wear your hearing aid, can you hear clearly?
			___1 Very clear	___2 Clear	___3 Average
			___4 Unclear		___5 Very unclear

G6. Presently, do you need a cane, crutches or walker to help you walk?
		___0 No		___1 Yes

	G6.1 Before that fall, did you use a cane, crutches or walker to help you walk?
			___0 No			___1 Yes

H. 	BALANCE

I would like to ask you to do a few simple movements, to test your balance.
(Skip this section if the respondent is confined to a chair or bed.)
ACTIVITY			NORMAL		MUST ADJUST	ABNORMAL
H1. Sitting 			___1 Steady		___2 Needs to hold	___3 Slouches, or
									onto chair arms to 	falls from the chair
									sit upright
H2. Standing up from
a sitting position		___1 Can stand up	___2 Needs to use	___3 Needs to try a
					at once without 	a handrail or other	number of times or
					holding onto a		device, or needs to	need someone’s help					  handrail			bend forward
H3. First 3-5 seconds
after standing up		___1 Steady		___2 Steady, but 	___3 Not steady at									  needs to use a     all
									support
H4. Standing			___1 Steady		___2 Steady, but	___3 Not steady at 
									leans			all, or needs to hold
													onto something
H5. Standing with eyes
closed				___1 Steady		___2 Steady, but	___3 Not steady at
									needs to stand with	all, or needs to hold
									feet apart			onto something
H6. Turn 360 degrees	___1 Steady, and	___2 Cannot make	___3 Not steady at
					can turn in a 		a continuous circle	all, or needs to hold
					continuous circle					onto something
H7. Rub chest (3 times)	___1 Steady, can	___2 Must move	___3 Starts to fall,
					cope with effects	feet, but can still	needs someone’s					    of thrust			maintain balance	help to maintain
                            balance   
  
H8. Rotate head		___1 Can turn 	___2 Can turn head	___3 When turning
					head and look up	and look up, but 	head or looking up
					with no problem	with less ability, but will become							no major problem          unsteady	  
H9. Stand on one leg	___1 Can stand on					___3 Cannot do it
					one leg for 5 						at all
					seconds or more
H10. Stretch/arch back	___1 Can stretch	___2 Can stretch, 	___3 Cannot stretch					well, without using	but to a lesser 		at all, or will become					a support or 		extent			shaky
					becoming shaky
H11. Reaching/raising
arms					___1 Can stand on	___2 Must hold 	___3 Cannot do it
					tiptoes to reach an	onto something	at all
					object in a high 	to reach an object
					place, without a	in a high place
					support or 
					becoming unsteady	
H12. Flexibility		___1 Can bend 	___2 Can bend 	___3 Cannot bend
					down to pick up	down to pick up	down or must try
					something, and 	something, but		many times to stand
					stand up in one	needs a support	up
					motion, with no
					support
H13. Sit down			___1 Can sit down	___2 Needs to hold	___3 Falls into the
					in one motion,		onto something to	chair, or cannot				        without becoming	sit down, or cannot	judge the distance
					unsteady			sit down smoothly	to the chair

I. 	WALKING

I would like to ask you to walk a few steps to test your walking ability.
(Skip this section if the respondent is confined to a chair or bed.)
ACTIVITY						OBSERVATIONS
						NORMAL			ABNORMAL
I1. Starting out			___1 Not hesitant, walks	___2 Hesitant, must try several
						steadily				times, walks unsteadily
I2. Height of steps			___1 Feet leave the 	___2 Feet do not completely
						ground about 3-5		leave the ground, or are lifted
						centimeters			very high (more than 3-5 cm)
I3. Length of steps			___1 Distance between	___2 Distance between steps
						steps is at least one foot	is less than one foot
I4. Weight of steps			___1 Distance taken by	___2 Distance taken by both
						both feet is the same	feet is different, or always uses
											the same leg to step
I5. Continuity of steps		___1 When one foot 	___2 The entire foot must be
						touches the ground, the	on the ground, before the next
						next is already prepared	one prepares to be lifted, or						    to be lifted, continuous	will stop after each step, or     										    distance between steps changes
I6. Walk in a straight line	___1 Can walk in a		___2 Will walk toward 						        straight line			one side or from side to side
I7. Stability				___1 The upper body	___2 Not at all steady
						is steady, knees or back
						do not bend.  Arms do
						not need to move away
						from body to maintain
						balance
I8. Walking 				___1 Walks one foot	___2 Cannot walk one foot
						in front of the other			in front of the other
I9. Turning				___1 Steady and		___2 Unsteady and halting
						continuous

Date and time when interview is completed:

_____ Y _____ M _____ D	
___1 AM 	___2 PM		Time: ______________