To help with our study, you will be asked several questions regarding your exercise activities, your balance and falls history, your medical history, and your demographics.
First, we will ask for your name so we can ensure any future information or data we collect can be matched with any previous information or data you've provided. This is the only use for your name, and it will not be included in any presentation or discussion of the results of this study.
The following questions will ask for some basic information about your current exercise activities. "Exercise" is considered to be any form of physical activity with the main purpose of sustaining or improving health or fitness.
Please answer these questions to the best of your ability. If you are uncertain of an answer, please select the answer you think most applies to you.
The following questions will ask for some basic information related to your history of falls or falling. For the purposes of these questions, a fall is considered to be:
an event [such as a loss of balance, a trip/stumble, or some other disruption to normal posture] which results in a person coming to rest inadvertently on the ground or floor or other lower level [with or without a subsequent injury].
The following questions relate to your medical history. They are general yes/no questions and will not require you to provide any specific details.
Demographic information helps put the results of our study into context by understanding who the results represent, and equally as important, who they might not represent. It also helps identify any limitations or gaps in the study which may guide future research.
This information is voluntary and while you are encouraged to answer all the questions, you may choose to answer any, all, or none of the questions.
Please consider the statements below and indicate you have read and accepted them by checking the boxes next to them. You must check both boxes in order to be able to submit this form.
If you have any questions please contact Ray Gates at: rayg@wisconsintaichiacademy.com prior to submitting this form.
I consent to the use of the information I provide for the purposes of gathering data for this study, including any test results, and understand that any identifying information, such as my name, will be removed from any presentation or discussion of the results of this study.
I understand that my participation in this study is voluntary, and I reserve the right to withdraw my consent and refuse further participation at any time.
