For each of the following activities, please indicate your level of self-confidence by choosing a corresponding number from the following rating scale: 0%10%20%30%40%50%60%70%80%90%100% No confidenceCompletely confident How confident are you that you will not lose your balance or become unsteady when you…1. Walk around the house?0%10%20%30%40%50%60%70%80%90%100%2. Walk up or down stairs?0%10%20%30%40%50%60%70%80%90%100%3. Bend over and pick up a slipper (or item) from the front of a closet floor?0%10%20%30%40%50%60%70%80%90%100%4. Reach for a small can off a shelf at eye level?0%10%20%30%40%50%60%70%80%90%100%5. Stand on your tiptoes and reach for something above your head?0%10%20%30%40%50%60%70%80%90%100%6. Stand on a chair and reach for something?0%10%20%30%40%50%60%70%80%90%100%7. Sweep the floor?0%10%20%30%40%50%60%70%80%90%100%8. Walk outside the house to a car parked in the driveway?0%10%20%30%40%50%60%70%80%90%100%9. Get into or out of a car?0%10%20%30%40%50%60%70%80%90%100%10. Walk across a parking lot to the mall (store)?0%10%20%30%40%50%60%70%80%90%100%11. Walk up or down a ramp?0%10%20%30%40%50%60%70%80%90%100%12. Walk in a crowded mall where people rapidly walk past you?0%10%20%30%40%50%60%70%80%90%100%13. Are bumped into by people as you walk through the mall?0%10%20%30%40%50%60%70%80%90%100%14. Step onto or off an escalator while you are holding onto a railing?0%10%20%30%40%50%60%70%80%90%100%15. Step onto or off an escalator while holding onto parcels such that you cannot hold onto the railing?0%10%20%30%40%50%60%70%80%90%100%16. Walk outside on icy sidewalks?0%10%20%30%40%50%60%70%80%90%100%Total NumberScores lower than 50 indicate a low level of functioning, scores above 50 but below 80 indicate a medium level, and those over 80 indicate a high level of functioning. Δ
