Baseline Questionnaire - GeroNet

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4. Were you limited in any activities other than householdactivities, such as hobbies, shopping, recreational,social, or religious activities? If so, why?___ Yes, health related___ Yes, not health related___ NoIA
ID#___________NIA BATTERY ADMINSTRATION PROTOCOL: longI. Summary Performance ScaleStanding BalanceTimed 8 Foot WalkTimed Repeat Chair StandsTOTALTimexxxxxxSCORECategoryScoreII. Standing BalanceA. No aids, such as walker or cane, may be used forthis task.B. Start with semi-tandem stand.1. Do full tandem if subject holds semi-tandem for10 seconds.2. Do side by side if subject fails to hold semitandemfor 10 seconds.c. Score is determined by highest level successfullycompleted.Example 1: Score is 3 if subject holds semi-tandem for10 seconds and full tandem for 5 seconds.Example 2: Score is 1 if subjects fails to hold semitandemfor 10 seconds but holds side by side for 10seconds.CategoryScorea. Side by Side:Feet parallel andtouching.b. Semi-Tandem:Heel of one foot toside of big toe ofother foot.c. Full Tandem:Heel of one foottouches big toe oother foot.(circle)Time: ________secs.0 Held 0-9 seconds ortried but unable ornot attempted.Time: ________secs.Held 0-9 seconds ortried but unable ornot attempted. Tryside by side ifappropriate.1 Held 10 seconds. Held 0-9 seconds ortried by unable ornot attempted.Time:_________sec2 Held 10 seconds. Held 0-2 secondstried but unablenot attempted.3 Held 10 seconds. Held 3-9 seconds4 Held 10 seconds. Held 10 seconds.
Page 1 and 2: O3base16.fmBASELINE QUESTIONNAIRE T
Page 3 and 4: 5. Does your health now limit you i
Page 5 and 6: 17. During the past 4 weeks did you
Page 7 and 8: 25. During the past 4 weeks, how mu
Page 9 and 10: 33. I expect my health to get worse
Page 11 and 12: ID#________IAPATIENT SATISFACTION Q
Page 13 and 14: 9. All things considered, the medic
Page 15 and 16: 19. I am dissatisfied with some thi
Page 17 and 18: ID#__________IAQUALITY OF WELL-BEIN
Page 19 and 20: 11. Trouble talking (e.g. lisp, stu
Page 21 and 22: 1. Did you drive or ride in a car y
Page 23: F. DAILY ACTIVITIES:1. Did you use
Page 27 and 28: IAID#__________NIA BATTERY ADMINSTR
Page 29 and 30: Health Status Questionnaire (SF-36)

Baseline Questionnaire - GeroNet

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