ABC Scale

Patient First Name*
Patient Last Name*
Date Of Birth*
MM slash DD slash YYYY
For each of the following activities, please indicate your level of self-confidence by choosing a corresponding number from the following rating scale:

0% - No Confidence | 100% - Complete Confident
How confident are you that you will not lose your balance or become unsteady when you…
Walk around the house?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Walk up or down stairs?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Bend over and pick up a slipper (or item) from the front of a closet floor?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Reach for a small can off a shelf at eye level?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Stand on your tiptoes and reach for something above your head?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Stand on a chair and reach for something?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Sweep the floor?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Walk outside the house to a car parked in the driveway?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Get into or out of a car?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Walk across a parking lot to the mall (store)?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Walk up or down a ramp?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Walk in a crowded mall where people rapidly walk past you?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Are bumped into by people as you walk through the mall?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Step onto or off an escalator while you are holding onto a railing?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Step onto or off an escalator while holding onto parcels such that you cannot hold onto the railing?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Walk outside on icy sidewalks?*
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Today's Date: 10/04/2023
Comments
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ABC Scale

How confident are you that you will not lose your balance or become unsteady when you…

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