do the activity (example: if someone does your shopping for you), please answer to show how you think you currently don’t would feel about falling IF you did the activity. Initial Assessment date: Independent Not Little Worried Very Comments Worried worried Worried (circle) 1 2 4 3 SU Name: DOB: 1 Cleaning the house (eg: sweep, vacuum, Yes No dust) Assisted 2 Getting dressed or undressed Yes No Assisted 3 Preparing simple meals Yes No Assisted 4 Taking a bath or shower Yes No Assisted 5 Going to the shop Yes No Assisted 6 Getting in or out of a chair Yes No Assisted 7 Going up or down stairs Yes No Assisted 8 Walking around in the neighbourhood Yes No Assisted 9 Reaching for something above your head Yes No or on the ground Assisted 10 Going to answer the telephone before it Yes No stops ringing Assisted 11 Walking on slippery surface (e.g: Wet or Yes No icy) Assisted 12 Visiting a friend or relative Yes No Assisted 13 Walking in a place with crowds Yes No Assisted 14 Walking on an uneven surface (e.g: Rocky Yes No ground, poorly maintained pavement) Assisted 15 Walking up or down a slope Yes No Assisted 16 Going out to a social event (e.g: religious Yes No service, family gathering or club meeting) Assisted (add up each column and put in the total) Total: /64 Any Comments: Are you a (delete as appropriate) OT / PT Do you believe this is a true reflection of the clients understanding? Yes / No Re- Assessment date: Independent Not Little Worried Very (circle) Worried worried Worried 1 2 3 4 Service user name: DOB: 1 Cleaning the house (eg: sweep, vacuum, Yes No dust) Assisted
currently don’t do the activity (example: if someone does your shopping for you), please answer to show how you think you would feel about falling IF you did the activity. Initial Assessment date: SU Name: DOB: Independent (circle) Not Worried 1 Little worried 2 Worried 3 Very Worried 4 Comments 1 Cleaning the house (eg: sweep, vacuum, dust) Yes No Assisted 2 Getting dressed or undressed Yes No Assisted 3 Preparing simple meals Yes No Assisted 4 Taking a bath or shower Yes No Assisted 5 Going to the shop Yes No Assisted 6 Getting in or out of a chair Yes No Assisted 7 Going up or down stairs Yes No Assisted 8 Walking around in the neighbourhood Yes No Assisted 9 Reaching for something above your head or on the ground Yes No Assisted 10 Going to answer the telephone before it stops ringing Yes No Assisted 11 Walking on slippery surface (e.g: Wet or icy) Yes No Assisted 12 Visiting a friend or relative Yes No Assisted 13 Walking in a place with crowds Yes No Assisted 14 Walking on an uneven surface (e.g: Rocky ground, poorly maintained pavement) Yes No Assisted 15 Walking up or down a slope Yes No Assisted 16 Going out to a social event (e.g: religious service, family gathering or club meeting) Yes No Assisted (add up each column and put in the total) Total: /64 Any Comments: Are you a (delete as appropriate) OT / PT Do you believe this is a true reflection of the clients understanding? Yes / No Re- Assessment date: Service user name: DOB: Independent (circle) Not Worried 1 Little worried 2 Worried 3 Very Worried 4 1 Cleaning the house (eg: sweep, vacuum, dust) Yes No Assisted
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