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 Yes No head or on the ground Assisted 10 Going to answer the telephone before Yes No it stops ringing Assisted 11 Walking on slippery surface (e.g: Wet Yes No or 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: Yes No Rocky ground, poorly maintained Assisted pavement) 15 Walking up or down a slope Yes No Assisted 16 Going out to a social event (e.g: Yes No religious service, family gathering or Assisted club meeting) (add up each column and put in the total) Total: /64 Any Comments: What was the pre and post intervention score: 1: / 64 2: /64 Is there a difference post intervention? Do you believe this is a true reflection of the clients understanding? Yes / No Intervention carried out: (ie: Skill development, equipment, AT provision, falls group etc). Therapist Name: Adapted from: Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., & Todd, C. (2005).Development and initial validation of the Falls Efficacy Scale- International (FES-I).Age 614-619. doi:10.1093/ageing/afi196. and Ageing, 34(6),
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: What was the pre and post intervention score: 1: / 64 2: /64 Is there a difference post intervention? Do you believe this is a true reflection of the clients understanding? Yes / No Intervention carried out: (ie: Skill development, equipment, AT provision, falls group etc). Therapist Name: Adapted from: Yardley, L., Beyer, N., Hauer, K., Kempen, G., Piot-Ziegler, C., & Todd, C. (2005).Development and initial validation of the Falls Efficacy Scale- International (FES-I).Age and Ageing, 34(6), 614-619. doi:10.1093/ageing/afi196.
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