Extremely Quite a bit Moderately Slightly Not at all
Not at all A little Somewhat A lot
Excellent Very good Good Fair Poor
10. In general, would you s
ay that your health is:
The next few questions ask about falls. By a fall, we mean when a person unintentionally
comes to rest on the ground or another lower level.
11. In the past 3 months, how many times have you fallen? O none O times
If you fell in the past 3 months:
a. how many of these falls caused an injury? (By an injury we mean the fall caused you to limit
your regular activities for at least a day or to go see a doctor.)
number of falls causing an injury
b.
where did the fall(s) occur (Please check all that apply)?
Indoors Outdoors Both indoors and outdoors
c. what happened after you fell and had an injury? (Please check all that apply)
Went to the Emergency Room
Visited my Primary Care Physician
Was admitted to the hospital
Did not seek medical care
12. How fearful are you of falling?
13. Please mark th
e circle that tells us how sure you are that you can do
the following activities.
How sure are you that:
14. During the last 4 weeks, to what extent has your concern about falling interfered
with your normal social activities with family, friends, neighbors or groups?
15. I have made safety modifications in my home, such as installing grab bars or securing
loose rugs, to reduce my risk of falling __ True __ False
16. What best descri
bes your activity level?
O Vigorously active for at least 30 min, 3 times per week
O Moderately active at least 3 times per week
O Seldom active, preferring sedentary activities
a. I can find a way to get up if I fall
O O O O
b. I can find a way to reduce falls
O O O O
c. I can protect myself if I fall
O O O O
d. I can increase my physical strength
O O O O
e. I can become more steady on my feet
O O O O
