Fall Prevention Participant Information Form

Enter Your Information

Required fields are marked with *

What is your race? Check all that apply

Has a health care provider ever told you that you have any of the following chronic conditions (i.e., one that has lasted for three months or more)? Check all that apply.

The next few questions ask about falls. By a fall, we mean when a person unintentionally comes to rest on the ground or another lower level.

If you fell in the past 3 months, what happened after you fell and had an injury? Check all that apply.