Self Assess your Level of Balance and Confidence in Movement.

How confident are you that you will not lose your balance and/ or become unsteady when...
0 = No confidence
100 = Complete confidence.

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1. Can you, walk around the house? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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2. Can you walk up and down stairs? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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3. Can you bend over and pick up a shoe from the floor? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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4. Can you reach for a small can off a shelf at eye level? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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5. Can you stand on your tiptoes and reach for something above your head? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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6. Can you stand on a chair and reach for something? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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7. Can you sweep or vacuum the floor? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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8. Can you walk to a taxi that is waiting by the sidewalk? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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9. Can you get into or out of a car? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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10. Can you cross a street? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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11. Can you step onto or off a curb? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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12. Can you walk on a street where people are rapidly passing? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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13. Can you walk on a street where other people bump into you as you walk? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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14. Can you travel by bus without a bag of groceries (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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15. Can you travel by bus with a bag of groceries (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.

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16. Can you walk on icy or slippery sidewalks? (Required.)

0 50 100
Clear
i We adjusted the number you entered based on the slider’s scale.
0 of 16 answered
 

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