Confidence Survey

Answer the following question about each activity listed. Please indicate your level of self-confidence by choosing a corresponding number from the following scale.

"How confident are you that you will NOT lose your balance or become unsteady when you...?" 

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* 1. ....walk around the house

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* 2. ...walk up or down the stairs?

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* 3. ...bend over and pick up a slipper from the front of a closet floor?

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* 4. ...reach for a small can off a shelf at eye level?

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* 5. ...stand on your tiptoes and reach for something above your head?

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* 6. ...get into or out of a car?

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* 7. ...walk across a parking lot to the mall?

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* 8. ...walk in a crowded mall where people rapidly walk past you?

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* 9. ...are bumped into by people as you walk through the mall?

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* 10. Name 

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