EXT B4 CDR Form and Dictionary
| Falls Efficacy Scale Form | ||
|
Download Dictionary: |
||
| Variable / Field Name | Field Label | Choices, Calculations, OR Slider Labels |
|---|---|---|
| falls_efficacy_adcid | Site: 39 ADCID | falls_efficacy_ptid | Subject ID: PTID | falls_efficacy_date | Form Date: (Y-M-D) | falls_efficacy_visitnum | Visit number: 1 (Initial visit), 2 and up (Follow up visit) VISITNUM | falls_efficacy_examiner | Examiner's initials: INITIALS | falls_admin_sts | Administered Status | 1, 1 Yes | 95, 95 - No, Physical Problem | 96, 96 - No, Cognitive/Behavior Program | 97, 97 - No, Other Problem | 98, 98 - No, Verbal Refusal | 99, 99 - Not Administered | fall_efficacy_1 | 1. Cleaning the house (e.g., sweeping, vacuuming, or dusting) | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_2 | 2. Getting dressed or undressed | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_3 | 3. Preparing simple meals | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_4 | 4. Taking a bath or shower | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_5 | 5. Going shopping | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_6 | 6. Getting in or out of a chair | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_7 | 7. Going up or down stairs | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_8 | 8. Walking around in the neighborhood | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_9 | 9. Reaching for something above your head or on the ground | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_10 | 10. Going to answer the telephone before it stops ringing | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_11 | 11. Walking on a slippery surface (e.g., on a wet or icy surface) | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_12 | 12. Visiting a friend or relative | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_13 | 13. Walking in a place with crowds | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_14 | 14. Walking on an uneven surface (e.g., on rocky ground or poorly maintained pavement) | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_15 | 15. Walking up or down a slope | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | fall_efficacy_16 | 16. Going out to a social event (e.g., to a religious service, family gathering, or club meeting) | 1, Not at all concerned | 2, Somewhat concerned | 3, Fairly concerned | 4, Very concerned | subtotal_1 | Subtotal (1-16): Not at all Concerned | if([fall_efficacy_1]=1,1,0)+if([fall_efficacy_2]=1,1,0)+if([fall_efficacy_3]=1,1,0)+if([fall_efficacy_4]=1,1,0)+if([fall_efficacy_5]=1,1,0)+if([fall_efficacy_6]=1,1,0)+if([fall_efficacy_7]=1,1,0)+if([fall_efficacy_8]=1,1,0)+if([fall_efficacy_9]=1,1,0)+if([fall_efficacy_10]=1,1,0)+if([fall_efficacy_11]=1,1,0)+if([fall_efficacy_12]=1,1,0)+if([fall_efficacy_13]=1,1,0)+if([fall_efficacy_14]=1,1,0)+if([fall_efficacy_15]=1,1,0)+if([fall_efficacy_16]=1,1,0) | subtotal_2 | Subtotal (1-16): Somewhat Concerned | if([fall_efficacy_1]=2,1,0)+if([fall_efficacy_2]=2,1,0)+if([fall_efficacy_3]=2,1,0)+if([fall_efficacy_4]=2,1,0)+if([fall_efficacy_5]=2,1,0)+if([fall_efficacy_6]=2,1,0)+if([fall_efficacy_7]=2,1,0)+if([fall_efficacy_8]=2,1,0)+if([fall_efficacy_9]=2,1,0)+if([fall_efficacy_10]=2,1,0)+if([fall_efficacy_11]=2,1,0)+if([fall_efficacy_12]=2,1,0)+if([fall_efficacy_13]=2,1,0)+if([fall_efficacy_14]=2,1,0)+if([fall_efficacy_15]=2,1,0)+if([fall_efficacy_16]=2,1,0) | subtotal_3 | Subtotal (1-16): Fairly Concerned | if([fall_efficacy_1]=3,1,0)+if([fall_efficacy_2]=3,1,0)+if([fall_efficacy_3]=3,1,0)+if([fall_efficacy_4]=3,1,0)+if([fall_efficacy_5]=3,1,0)+if([fall_efficacy_6]=3,1,0)+if([fall_efficacy_7]=3,1,0)+if([fall_efficacy_8]=3,1,0)+if([fall_efficacy_9]=3,1,0)+if([fall_efficacy_10]=3,1,0)+if([fall_efficacy_11]=3,1,0)+if([fall_efficacy_12]=3,1,0)+if([fall_efficacy_13]=3,1,0)+if([fall_efficacy_14]=3,1,0)+if([fall_efficacy_15]=3,1,0)+if([fall_efficacy_16]=3,1,0) | subtotal_4 | Subtotal (1-16): Very Concerned | if([fall_efficacy_1]=4,1,0)+if([fall_efficacy_2]=4,1,0)+if([fall_efficacy_3]=4,1,0)+if([fall_efficacy_4]=4,1,0)+if([fall_efficacy_5]=4,1,0)+if([fall_efficacy_6]=4,1,0)+if([fall_efficacy_7]=4,1,0)+if([fall_efficacy_8]=4,1,0)+if([fall_efficacy_9]=4,1,0)+if([fall_efficacy_10]=4,1,0)+if([fall_efficacy_11]=4,1,0)+if([fall_efficacy_12]=4,1,0)+if([fall_efficacy_13]=4,1,0)+if([fall_efficacy_14]=4,1,0)+if([fall_efficacy_15]=4,1,0)+if([fall_efficacy_16]=4,1,0) | short_subtotal_1 | Short Version Subtotal (Items 2, 4, 6, 7, 9, 15, 16): Not at all Concerned | if([fall_efficacy_2]=1,1,0)+if([fall_efficacy_4]=1,1,0)+if([fall_efficacy_6]=1,1,0)+if([fall_efficacy_7]=1,1,0)+if([fall_efficacy_9]=1,1,0)+if([fall_efficacy_15]=1,1,0)+if([fall_efficacy_16]=1,1,0) | short_subtotal_2 | Short Version Subtotal (Items 2, 4, 6, 7, 9, 15, 16): Somewhat Concerned | if([fall_efficacy_2]=2,1,0)+if([fall_efficacy_4]=2,1,0)+if([fall_efficacy_6]=2,1,0)+if([fall_efficacy_7]=2,1,0)+if([fall_efficacy_9]=2,1,0)+if([fall_efficacy_15]=2,1,0)+if([fall_efficacy_16]=2,1,0) | short_subtotal_3 | Short Version Subtotal (Items 2, 4, 6, 7, 9, 15, 16): Fairly Concerned | if([fall_efficacy_2]=3,1,0)+if([fall_efficacy_4]=3,1,0)+if([fall_efficacy_6]=3,1,0)+if([fall_efficacy_7]=3,1,0)+if([fall_efficacy_9]=3,1,0)+if([fall_efficacy_15]=3,1,0)+if([fall_efficacy_16]=3,1,0) | short_subtotal_4 | Short Version Subtotal (Items 2, 4, 6, 7, 9, 15, 16): Very Concerned | if([fall_efficacy_2]=4,1,0)+if([fall_efficacy_4]=4,1,0)+if([fall_efficacy_6]=4,1,0)+if([fall_efficacy_7]=4,1,0)+if([fall_efficacy_9]=4,1,0)+if([fall_efficacy_15]=4,1,0)+if([fall_efficacy_16]=4,1,0) | total | Total (Items 1-16) | [fall_efficacy_1]+[fall_efficacy_2]+[fall_efficacy_3]+[fall_efficacy_4]+[fall_efficacy_5]+[fall_efficacy_6]+[fall_efficacy_7]+[fall_efficacy_8]+[fall_efficacy_9]+[fall_efficacy_10]+[fall_efficacy_11]+[fall_efficacy_12]+[fall_efficacy_13]+[fall_efficacy_14]+[fall_efficacy_15]+[fall_efficacy_16] | short_total | Short Version Total (Items 2, 4, 6, 7, 9, 15, 16): | [short_subtotal_1]+[short_subtotal_2]+[short_subtotal_3]+[short_subtotal_4] |