OTAGO OUTCOMES DATABASE:
BASELINE OUTCOME DATA -- ENTRY FORM
NOTE TO THERAPIST: The Baseline Survey is to be completed during Otago Visit 1, while your patient is
present.
NOTE: Optional -- These fields will be assigned and automatically recorded within patient records in
the Otago Outcomes Database. Use this section on the paper data entry forms to assist with filing
and record keeping outside if the database (if necessary).
Therapist ID:
__-___
Patient ID:
__-___-___
Patient Name:
First: _____________________ Last Initial: ____
Date of Visit:
_ _ /_ _ / _ _ _ _
PATEINT PERSPECTIVE
Instructions to Therapist: Please ask the following questions and read the possible answers to your
patient. Please record the patient’s answer for each question:
1. Would you say that in general your health is:
□ Excellent
□ Very good
□ Good
□ Fair
2. How satisfied are you with your current physical activity levels?
□ Very
□ Mostly
□ Somewhat
□ Poor
□ Not at all
3. Please rate your level of agreement with the following statement:
“Would you say you feel confident that you can keep yourself from falling?”
□ Strongly Agree
□ Agree
□ Disagree
□ Strongly Disagree
4. For the next five scenarios, choose the most appropriate answer from the following choices:
No
Some
Much
Unable to
How much difficulty do you have:
Difficulty
Difficulty
Difficulty
Do
□
□
□
□
Walking across a room?
□
□
□
□
Walking one block?
□
□
□
□
Stooping, crouching, or kneeling?
□
□
□
□
Getting out of a straight back chair?
□
□
□
□
Climbing one flight of stairs?
5. How often do you restrict your activities because of difficulties in walking?
□ Never
□ Seldom
□ Sometimes
□ Often
□ Always
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Otago Outcomes Database | Baseline Survey
6. How often do you have someone to help you with your exercises between Physical Therapy visits?
□ Never
□ Seldom
□ Sometimes
□ Often
□ Always
7. Please rate how often you will be able to do your Otago Exercise Program exercises 3 or more
times per week.
□ Never
□ Seldom
□ Sometimes
□ Often
□ Always
8. Did your physician or other healthcare provider refer you to the Otago Exercise Program?
 Yes
 No
9. Besides your physical therapist, have you ever heard about the Otago Exercise Program from any
other sources?
 Yes
 No
If Yes, then please answer the following question:
Where or how have you heard about Otago? (Select all that apply):
 Friend or family member
 Aging & Disability Services
 Hospital/health care provider
 Local Health Department
 Healthy Aging Network
 TV, radio, or newspaper
 Recreation Center/YMCA
 Health Fair or other even
 Home Health Agency
 Senior Center
 Other (please specify):
_________________________
10. Have you ever participated in or has a Physical Therapist given you exercises from the Otago
Exercise Program before now?
 Yes
 No
THERAPIST PERSPECTIVE
Instructions to Therapist: Please answer the following questions about your patient:
1. Total number of weeks of physical therapy prior to starting Otago:
0
1
2
3
4
5
6
7
8
9
(10 or more)
2. Total number of PT visits prior to starting Otago:
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 (20 or more)
3. Does the patient have fear of falling?
 Yes
 No
4. Has the patient fallen in past 12 months?
□ Yes
□ No
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Otago Outcomes Database | Baseline Survey
If Yes, then please answer the following questions:
Number of falls in past 12 months:
1 2 3 4 (5 or more)
Number of falls resulting in injuries:
1 2 3 4 (5 or more)
Number of falls resulting in ED visits:
1 2 3 4 (5 or more)
Number of falls resulting in hospitalization:
1 2 3 4 (5 or more)
FUNCTIONAL MEASURES
TUG:
Record time to nearest tenth of a second (0.0 sec)
_________ seconds
Self-selected walking speed:
Record walking speed in meters/second
_________ m/s
30 Second Chair Stand:
Record number of completed raises
_________ raises
1
2
3
4
□
□
□
□
<2
2-5
6 -10
10 ≤
□
□
□
□
Four Stage Balance Test:
Select the position the patient achieved for 10 seconds
Endurance:
Approximate time (in minutes) the patient can walk
independently with or without an aid
If any of the functional measures were not performed, please explain why:
□
By checking this box, you are confirming that all information on the Baseline Outcome Data
Entry Form for this patient is correct and complete.
You have now completed the Baseline Outcome Data. Thank you for your time.
Remember to transfer information from this paper entry form to the Otago Outcomes Database:
https://apps.hpdp.unc.edu/Otago
Please remember to collect and record the 8 Week Follow-Up Outcome Data for this patient.
You will receive an e-mail reminder.
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