The falls related survey

Age ( 年龄)

0-24
25-44
45-54
55-64
65-74
75-84
85-94
95+

Gender (性别)

Male ( 男)

Female (女)

Don‘t want to say (不方便讲)

Have you ever fallen before?
（你曾经摔倒过吗？）

Yes

No

Have yo ever got serious injuries because of fall?
(你是否曾因为摔倒而严重受伤？)

Yes

No

Have you fallen seriously twice or more?
你曾经是否很严重地摔倒过一次或两次以上？

Yes, only once. (是的，只有一次)

Yes, twice and more. (是的，两次以上)

Yes, but it is not serious （是的，但并不严重）

No （没有过）

How many times have you fallen seriously?
(你曾严重地摔倒过几次？)

once （1次）

twice （2次）

3 times（3次）

more than 4 times（4次以上）

Do you have family member/ friend or hear the others who dead because of fall and related injuries?
(你是否有家人，朋友，或者听说过，有人因摔倒和摔倒造成的伤害而导致死亡？)

Yes

No

What the age you know who dead of fall?
( 你所知道那位因跌倒而去世的人的年龄段是？)

Is there any special furniture in your house to prevent fall for older adults? such like handrail, lower footstep...
(你家是否有专门的设备来阻止老人跌倒？比如扶手，更低的台阶...)

Yes

No

What is that furniture? please write here(请写出这个家具):