Falls and Fear of Falling in Adults who Require Wheelchairs for Locomotion

 

Instructions: Please complete the questionnaire to answer questions about the history of your neurological condition, your overall mobility, fall history, and concern of falling. Answer the questions to the best of your ability. It will take approximately 20 minutes to complete this questionnaire. The return of your completed questionnaire constitutes your informed consent to act as a participant in this research. If you have any questions or concerns about the questionnaire, you may contact Carolyn Da Silva, PT, DSc, NCS at 713-794-2087 or cdasilva@twu.edu

*1)
What is your primary neurological diagnosis (the main reason you use a wheelchair)?

YearsMonths
*2)How long ago were you diagnosed with your primary neurological condition? Enter 0 months, after the years, if your condition is chronic or you don't know.
3)
Please select other neurological diagnoses you may have, in addition to what you listed as your primary diagnosis.

*4)
What percent of your day do you use your wheelchair for locomotion inside your home?

Continue ONLY when finished. You will be unable to return or change your answers.

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