Not at all Somewhat Fairly Very concerned concerned concerned concerned 1 2 3 4 1 Cleaning the house 1 2 3 4 (e.g. sweep, vacuum or dust) 2 Getting dressed or 1 2 3 4 undressed 3 Preparing simple 1 2 3 4 meals 4 Taking a bath or 1 2 3 4 shower 5 Going to the shop 1 2 3 4 6 Getting in or out of a 1 2 3 4 chair 7 Going up or down 1 2 3 4 stairs 8 Walking around in 1 2 3 4 the neighbourhood 9 Reaching for 1 2 3 4 something above your head or on the ground 10 Going to answer the 1 2 3 4 telephone before it stops ringing 11 Walking on a 1 2 3 4 slippery surface (e.g. wet or icy) 12 Visiting a friend or 1 2 3 4 relative 13 Walking in a place 1 2 3 4 with crowds 14 Walking on an 1 2 3 4 uneven surface (e.g.
Not at all concerned 1 Somewhat concerned 2 Fairly concerned 3 Very concerned 4 1 Cleaning the house (e.g. sweep, vacuum or dust) 1 2 3 4 2 Getting dressed or undressed 1 2 3 4 3 Preparing simple meals 1 2 3 4 4 Taking a bath or shower 1 2 3 4 5 Going to the shop 1 2 3 4 6 Getting in or out of a chair 1 2 3 4 7 Going up or down stairs 1 2 3 4 8 Walking around in the neighbourhood 1 2 3 4 9 Reaching for something above your head or on the ground 1 2 3 4 10 Going to answer the telephone before it stops ringing 1 2 3 4 11 Walking on a slippery surface (e.g. wet or icy) 1 2 3 4 12 Visiting a friend or relative 1 2 3 4 13 Walking in a place with crowds 1 2 3 4 14 Walking on an uneven surface (e.g. 1 2 3 4
368830-Participation_Assessment_Booklet_version1.docx