Stay Strong, Stay Healthy Three Month Follow Up Survey

General

Participant ID

Age

Gender

Female

Male

Other

Please select one of the options.

Gender (Other)

SSSH instructor name

this is a required field

County in which SSSH course was held

State in which SSSH course was held

KS

MO

NC

NV

TN

this is a required field

How many days per week do you currently engage in the following?

Strength training exercises

None

1 Day per week

2 - 3 Days per week

4+ Days per week

Please select one of the options.

Aerobic activities such as walking, swimming, biking, etc.

None

1 Day per week

2 to 3 Days per week

4+ Days per week

Please select one of the options.

Stretching or flexibility exercises

None

1 Day per week

2 - 3 Days per week

4+ Days per week

Please select one of the options.

Balance exercises, such as yoga or tai chi

None

1 Day per week

2 - 3 Days per week

4+ Days per week

Please select one of the options.

Understanding of strength training

I currently describe my knowledge , skills and understanding of strength training exercise as:

Extremely adequate

Somewhat adequate

Neither adequate nor inadequate

Somewhat inadequate

Extremely inadequate

Please select one of the options.

Please rate your concern about falling while doing the following activities. If you currently do not do the activity, please answer to show whether you think you would be concerned about falling IF you did the activity.

Getting dressed or undressed

Very concerned

Fairly concerned

Neutral

Somewhat concerned

Not at all concerned

Please select one of the options.

Taking a bath or shower

Very concerned

Fairly concerned

Neutral

Somewhat concerned

Not at all concerned

Please select one of the options.

Getting in or out of a chair

Very concerned

Fairly concerned

Neutral

Somewhat concerned

Not at all concerned

Please select one of the options.

Going up or down stairs

Very concerned

Fairly concerned

Neutral

Somewhat concerned

Not at all concerned

Please select one of the options.

Reaching for something above your head or on the ground

Very concerned

Fairly concerned

Neutral

Somewhat concerned

Not at all concerned

Please select one of the options.

Walking up or down an incline or uneven surface

Very concerned

Fairly concerned

Neutral

Somewhat concerned

Not at all concerned

Please select one of the options.

Going out to a social event (e.g., religious service, family gathering, movie or restaurant)

Very concerned

Fairly concerned

Neutral

Somewhat concerned

Not at all concerned

Please select one of the options.

Please indicate to what extent the following items are affected by your health:

Does your energy level limit you from completing everyday tasks?

A great deal

A lot

A moderate amount

A little

None at all

Please select one of the options.

Does your health limit you in moderate activities, such as housecleaning, pushing a vacuum, golf, bowling or moving a table?

A great deal

A lot

A moderate amount

A little

None at all

Please select one of the options.

Does your health limit you when climbing several flights of stairs?

A great deal

A lot

A moderate amount

A little

None at all

Please select one of the options.

After the Stay Strong, Stay Healthy course ended, have you:

Increased the amount of weight used during strength training exercises?

Yes

No

Please select one of the options.

Purchased personal weights for home use?

Yes

No

Please select one of the options.

Added any other physical activities to your weekly schedule (e.g. walking, water aerobics, etc.)?

Yes

No

Please select one of the options.

After participating in the Stay Strong, Stay Healthy course:

Do you feel that your overall health is better?

A great deal

Somewhat

Not at all

Please select one of the options.

Do you feel physically stronger?

A great deal

Somewhat

Not at all

Please select one of the options.

Do you sleep better?

A great deal

Somewhat

Not at all

Please select one of the options.

Are your joints less painful, due to arthritic pain?

A great deal

Somewhat

Not at all

Please select one of the options.

Course rating

Have you recommended this course to anyone else?

Yes

Maybe

No

Please select one of the options.

Have you experienced any health problems since this course ended that would affect the way you respond to these questions?

Yes

No

Please select one of the options.

If yes, please explain

Is there anything that you do now that you couldn't do before taking the course?

Are you finished with this survey?

yes

no

Please select one of the options.

Please select one of the options.