Fyzical - MFES - Initial Visit

MFES - Initial Visit
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Date

Month Day Year
Date
Please rate your pain level with activity:
NO PAIN = 0 1 2 3 4 5 6 7 8 9 10 = VERY SEVERE PAIN
INSTRUCTIONS: On a scale of 0 to 10, how confident are you that you can do each of these activities without falling, with 0 meaning "not confident/not sure at all", 5 being "fairly confident/fairly sure", and 10 being "completely confident/completely sure"? If you have stopped doing the activity at least partly because of being afraid of falling, score a 0; If you have stopped an activity purely because of a physical problem, leave that item blank If you do not currently do the activity for other reasons, please rate that item based on how you perceive you would rate if you had to do the activity today.
1. Get dressed and undressed.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
2. Prepare a simple meal.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
3. Take a bath or as shower.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
4. Get in/out of a chair.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
5. Get in/out of bed.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
6. Answer the door or telephone.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
7. Walk around the inside of your house.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
8. Reach into cabinets or closet.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
9. Light housekeeping.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
10. Simple shopping.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
11. Using public transport.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
12. Crossing roads.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
13. Light gardening or hanging out the washing*
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
14. Using front or rear steps at home.
NOT CONFIDENT AT ALL = 0, FAIRLY CONFIDENT = 5, COMPLETELY CONFIDENT = 10
*Rate most commonly performed of these activities.
Score /140
PERCENTAGE (%)
Should be Empty: