Tai-chi pre-survey. In person. Sequence 1
Teacher: Rowena Richie,   Tuesdays, Thursdays 11:30-12:30  (20 classes) April 30 - July 9, 2024
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Guideline to the next question: enter first two letters of your first name, first two letters of your last name, last two numbers of your birth year. e.g.  John Smith born in 1943.  JOSM43
Ponga las dos primeras letras de su nombre, las dos primeras letras de su apellido, y los ultimos 2 nombres de su año de nacimiento. por ejemplo: Juan Garcia nacio en 1943. JUGA43 
Participant ID *
1. Did your doctor or other health care provider suggest that you attend this program?
1. ¿Asiste a este programa por sugerencia de su médico o proveedor de atención médica? 
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2.  How old are you today? years
2. ¿Cuántos años tiene hoy?        (años)
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3. Do you live alone?
3. ¿Vive solo/a? 
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4. Are you:
4. Usted es:
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5. Are you of Hispanic, Latino, or Spanish origin?
5. ¿Es usted de origen hispano, latino o español? 
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6. What is your race? Check all that apply.

6. ¿Cuál es su raza? Marque todo lo que corresponda.

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Required
7. What is the highest grade or level of school that you have completed?
7.¿Cuál es el grado o nivel más alto de la escuela que ha completado?
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8. 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 Yes or No
8. ¿Alguna vez un proveedor de atención médica le ha dicho que tiene alguna de las siguientes condiciones crónicas (es decir, una que ha durado tres meses o más)? Seleccione Sí o No.
Yes
No
Alzheimer's Disease or other dementia
Anxiety Disorder (ansiedad)
Arthritis/Rheumatic Disease (Artritis)
Asthma/Emphysema/Other chronic breathing or lung problem
Cancer or cancer survivor
Chronic Pain (dolor crónico)
Depression
Diabetes (High blood sugar)
Hearth disease (enfermedad cardiaca)
High cholesterol (colesterol alto)
hypertension (High blood pressure)
Kidney disease (enfermedad del riñón)
Obesity (Obesidad)
Osteoporosis (Low bone density)
Parkinson's disease
Schizophrenia or other psychotic disorder
Stroke (embolia o ictus)
Traumatic Brain Injury (Daño cerebral traumático)
Urinary incontinence (incontinencia urinaria)
Other chronic condition (otra condición)
Clear selection
9. In general, would you say that your health is

9. En general, usted diría que su salud es:

Clear selection
10. How often do you feel lonely or isolated from those around you?
10. ¿Con qué frecuencia se siente solo/a o aislado/a de quienes le rodean?
Clear selection
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.

Las siguientes preguntas se refieren a las caídas. Por una caída, nos referimos a cuando una persona cae involuntariamente en el piso u otro nivel inferior.

11. In the past 3 months, how many times have you fallen?
11. En los últimos tres meses, ¿cuántas veces se ha caído?     
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Specify how many time you have fall in the past 3 months
especifique cuántas veces se ha caido en los últimos 3 meses.

a. how many of these falls caused an injury? (By an injury we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.
a. ¿Cuántas de estas caídas causaron una herida o lesión? (Una herida se refiere a una  caída que causó que usted limite sus actividades regulares durante al menos un día o viera a un médico
b. Did you tell anyone, such as a family member, friend, or healthcare provider about this fall, whether or not it resulted in an injury?

b.      Le habló a alguien, a un familiar, a un amigo o a un profesional de la salud, sobre esta caída, independientemente de que le haya provocado o no una lesión?

c. what happened after you fell? (Please check all that apply)

c. ¿Qué ocurrió después de la caída? (Por favor, marque todo lo que corresponda)

12. How fearful are you of falling?
12. ¿Qué tanto teme caerse?
Clear selection
13. During the last 4 weeks, to what extent has your concern about falling interfered with your normal social activities with family, friends, neighbors or groups?

13.   Durante las últimas cuatro semanas, ¿hasta qué punto su preocupación por caer ha interferido con sus actividades sociales usuales con familiares, amigos, vecinos o grupos?

Clear selection
14. Please mark the circle that tells us how sure you are that you can do the following activities. How sure are you that:

14.    Por favor marque con una X lo seguro/a que usted está de poder realizar las siguientes actividades. 

No at all sure (nada seguro)
Somewhat sure (algo seguro)
Neutral
Sure (seguro)
Very sure (muy seguro)
I can find a way to get up if I fall ( puedo encontrar la manera de levantarme si me caigo)
I can find a way to reduce falls ( puedo encontrar la manera de reducir las caidas)
I can increase my flexibility (puedo aumentar mi flexibilidad)
I can increase my physical strength (puedo aumentar mi fuerza fisica)
I can become more steady on my feet (puedo mantenerme firme sobre los pies)
Clear selection
15. What best describes your activity level?

15.    ¿Qué describe mejor su nivel de actividad?

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16. Have you taken this tai-chi for arthritis program before?

16.¿Ha tomado este programa de taichi anteriormente?

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17. Please indicate which type of insurance you have?
17. Que tipo de seguro de salud tiene?
If you mark a private insurance not listed above, what is the name:
Si marco un seguro privado que no esta en la lista anterior, cual es el nombre:
If you mark Medicare Adv HMO or Adv Plan SNP specify
LFT Pre-program questionnaire
Transportation
Very often
Often
Sometimes
Rarely
Never
In the past 30 days, how often have you had to reschedule an appointment because of a problem with transportation
In the past 30 days, how often have you skipped going someplace because of a problem with transportation?
Clear selection
Wellness and isolation
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I don't know
I am content with my friendships and relationships
I have enough people I feel comfortable asking for help at any time
My relationships are as satisfying as I would want them to be
Clear selection
Below are two statements that people have made about their food situation. For each statement, please indicate whether the statement was often true, sometimes true, or never true for your household in the last 12 months.
Very true
Sometimes true
Never true
We worried whether our food would run out before we got money to buy more.
The food we bought just didn’t last, and we didn’t have money to get more.
Clear selection
RELEASE FORM - ACKNOWLEDGEMENT OF PERSONAL RESPONSIBILITY/CONSENT for in person and online Tai-chi class.
I understand that tai chi is a gentle exercise, which may enhance my physical fitness. I confirm that my physical condition is fit to safely participate in these lessons.
In consideration for admission to this class:
(a) I hereby accept full responsibility for and assume the risk of any injuries sustained because of my participation in this practice or lessons involving tai chi.
(b) I hereby release and hold harmless the tai-chi instructor, and all personnel associated with the tai chi lessons for any liabilities, injuries and expenses which may arise as a result of participation in this practice or lessons involving tai chi.
I know of no medical reasons why I should not participate in this class. I understand that, if I do have any medical reasons why I should not participate in the class, it is my responsibility to obtain a clearance from my doctor before commencing.

Type your complete name and date as a proxy for your signature to accept the release of liability
Escriba su  nombre y fecha como un equivalente de su firma para aceptar la excepción de responsablidad
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Contact Person, name and phone, near your in case of emergency:
Persona de contact, nombre y telefono, en caso de emergencia
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