Plan Your Health Quiz

 

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 to 10=Completely Confident

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

1. … when you walk around the house?

 
 
 
 
 
 
 
 
 
 
 

2. …walk up or down stairs?

 
 
 
 
 
 
 
 
 
 
 

3. … bend over and pick up a slipper from the front of a closet floor?

 
 
 
 
 
 
 
 
 
 
 

4. …reach for a small can off a shelf at eye level?

 
 
 
 
 
 
 
 
 
 
 

5. …stand on your tiptoes and reach for something above your head?

 
 
 
 
 
 
 
 
 
 
 

6. …stand on a chair and reach for something?

 
 
 
 
 
 
 
 
 
 
 

7. …sweep the floor?

 
 
 
 
 
 
 
 
 
 
 

8. …walk outside the house to a car parked in the driveway?

 
 
 
 
 
 
 
 
 
 
 

9. …get into or out of a car?

 
 
 
 
 
 
 
 
 
 
 

10. …walk across a parking lot to the mall?

 
 
 
 
 
 
 
 
 
 
 

11. …walk up or down a ramp?

 
 
 
 
 
 
 
 
 
 
 

12. …walk in a crowded mall where people rapidly walk past you?

 
 
 
 
 
 
 
 
 
 
 

13. …are bumped into by people as you walk through the mall?

 
 
 
 
 
 
 
 
 
 
 

14. …step onto or off an escalator while you are holding onto a railing?

 
 
 
 
 
 
 
 
 
 
 

15. …step onto or off an escalator while holding onto parcels such that you cannot hold onto the railing?

 
 
 
 
 
 
 
 
 
 
 

16. …walk outside on icy sidewalks?