Saving Claire viewer survey
Thank you for taking the time to view the Saving Claire film, as part of the Saving Claire Falls Prevention Project. We hope you enjoyed it.

Because the things covered in the film are so important, we are requesting--Please!--your feedback so we can always keep improving. 

Please provide your personal answers to this quick survey and let us know your thoughts (your answers will be anonymous). 

The entire process usually takes LESS THAN 2 MINUTES.

Thank You!

Ames Productions
www.savingclaire.com
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What is your overall feeling about the Saving Claire film?
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We start with the most basic question because if you didn't care for it, we really want to understand why.
Didn't care for it
Liked it very much
Do you have any comments, reactions or suggestions to Saving Claire that you would like to share?
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Have you ever fallen? or perhaps tripped and almost fallen? *
If "yes" or "almost fallen", how many times? If "neither", chooose "0"
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Are you more aware of the risks of falling after viewing Saving Claire ? *
Are you more likely to take steps to reduce your personal fall risk now that you have seen the Saving Claire film? *
Would you like to have a no-cost personal fall risk assessment similar to the one shown in the film? *
Would you like to have a no-cost home fall risk assessment for your home?
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Do you exercise? *
Would you be interested in an exercise program to reduce the risk of falling?
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Do you take any medications or supplements on a regular basis? (please check all that apply)
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Daily
Weekly
Occasionally, based on need
Hardly ever or Never
Prescription Medications
Non-Prescription Medications (over the counter)
Supplements (vitamins and/or others)
Would you like to speak to a pharmacist about fall risk associated with your medications or supplements?
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Do you get annual check-ups?
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Do you get annual vision screenings?
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Do you get annual hearing screenings?
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OPTIONAL:
Please let us know if you would like to be contacted regarding any of the following. If so, please let us know your contact information.
Please check all that apply.
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Required
CONFIDENTIAL:
Please share only your first name and a phone number and/or email address.

Only provide if you would like to be contacted. This information will not be shared outside the service providers you have requested. 

You are under no obligation to work with anyone.
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