Instructions: Please Answer the Below questions.

1. Take a bath or shower

2. Reach into cabinets or closets

3. Walk around the house

4. Prepare meals not requiring carrying heavy or hot objects

5. Get in and out of bed

6. Answer the door or telephone

7. Get in and out of a chair

8. Getting dressed and undressed

9. Personal grooming (i.e. washing your face)

10. Getting on and off of the toilet


Bibliographic References (copyright belongs to the author/s of this instrument):

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  3. Hauer, K., Yardley, L., et al. (2010). "Validation of the Falls Efficacy Scale and Falls Efficacy Scale International in geriatric patients with and without cognitive impairment: results of self-report and interview-based questionnaires." Gerontology 56(2): 190-199.
  4. Hellstrom, K. and Lindmark, B. (1999). "Fear of falling in patients with stroke: a reliability study." Clinical rehabilitation 13(6): 509.
  5. Hotchkiss, A., Fisher, A., et al. (2004). "Convergent and predictive validity of three scales related to falls in the elderly." American Journal of Occupational Therapy 58(1): 100-103.