9 . آيا شما درخانه ماندن را به بيرون رفتن و انجام دادن کارهاي جديد ترجيح مي دهيد؟
بلی • خیر •

١0 . آيا شما فكر مي کنيد نسبت به اکثر افراد مشكل بيشتري با حافظه تان داريد؟
بلی • خیر •

١1 . آيا شما در حال حاضراز زنده بودن خود احساس بسيار خوبي داريد؟
بلی • خیر •

١2 . آيا شما در شرايط کنوني احساس بي ارزشي يا بي اهميتي مي کنيد؟
بلی • خیر •

13 . آيا شما احساس مي کنيد که پر انرژي هستيد؟
بلی • خیر •

14 . آيا شما احساس مي کنيد که وضعيت(موقعيت) فعلي شما نااميد کننده است؟
بلی • خیر •

15 . آيا شما فكر مي کنيد که بيشتر مردم نسبت به شما در شرايط بهتري هستند؟
بلی • خیر •

روش امتياز دهي:
براي هر پاسخ ها يك امتياز در نظر بگيريد
1 بلی 6 بلی 11 خیر
2 بلی 7 خیر 12 بلی
3 بلی 8 بلی 13 خیر
4 بلی 9 بلی 14 بلی
5 خیر 10 بلی 15 بلی

پیوست شماره ی 6
فرم رضایت نامه
بدین وسیله اینجانب ……………………………………… با آگاهی کامل رضایت خود را جهت شرکت در طرح تحقیقاتی «تاثیر راه رفتن دو تکلیفی بر هم آهنگی بین مفصلی در جوانان و سالمندان با و بدون سابقه زمین خوردن» که در دانشگاه های علوم بهزیستی و توانبخشی تهران ، به راهنمایی جناب آقای دکتر کریمی می باشد، اعلام مینمایم.

به اینجانب توضیح داده شده است که این پژوهش به بررسی تاثیر یک فعالیت هم زمان با راه رفتن بر الگوی راه رفتن می پردازد و جهت انجام این بررسی باید به مدت یک ساعت جهت انجام آزمون ها وقت بگذارم . شرکت دراین تحقیق ممکن است برای من فایده فوری نداشته باشد .

کلیه اطلاعاتی که از اینجانب گرفته میشود محرمانه باقی خواهد ماند و نتایج تحقیق به صورت جواب کلی گروه مورد بررسی، منتشر می گردد و نتایج فردی بدون ذکر نام عرضه خواهد شد .

پژوهشگر سوالات اینجانب را پاسخ داده و به من تفهیم شده است در هر لحظه که مایل باشم میتوانم از شرکت در پژوهش خودداری کنم . لذا من موافقت خود را جهت شرکت در این تحقیق اعلام مینمایم .

امضا ……………………………..
تاریخ ……………………………..

نشانی و تلفن : ………………………………………………………………………………………………….

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