Patient code (EUROSCA-R):
FALL QUESTIONNAIRE
Please tick only one item per question
A fall is defined as every event that results in you unintentionally ending up on the floor (or any other lower surface).
1.Do you live alone?
Yes
No, with partner
Otherwise namely.……………………………………………………………………….
……………………………………………………………………………………………………
2.What is your current living situation?
Autonomous
Accompanied living
Old people’s home
Sheltered accommodation
Resting home
Nursing home
3.What medication are you currently using?
Name of the medicine:Dose:Frequency per day:
......
......
......
......
......
......
......
......
5.How are your walking abilities at the moment?
Totally independent
With an aid (e.g. with a stick or stroller)
With the assistance of others
Walking is not possible
6.Did you ever experience a fall since the onset of disease?
No
Yes
7.What was time between the onset of disease and your first fall?
Month(s)……………….. Year(s)……………
8. How often do you fall?
Never
Every day
Every week
Every month
Every Year
9.Did you fall yesterday?
No
Once
More than once
10.Did you fall last week?
No
Once
More than once
11.Did you fall last month?
No
Once
More than once
If you answered questions 9 to 11 all with “No” as the answer, you may proceed to question 18. Otherwise proceed with answer 12.
12.Did you ever hurt yourself because of a fall?
No
Once
More than once
13.What kind of injuries have you suffered as a consequence of a fall?
None
A fracture, namely: (e.g. a hip)…………………………………………………………….
Other wounds (e.g. a bruise or excoriation)
Unconsciousness
Otherwise namely (e.g. a brain hemorrhage):………………………………………….
14.When you fall, where does this usually takes place?
Outdoors
Indoors
Both
15.When you fall, at what time does this usually takes place?
Every moment of the day
In the daytime
During the evening
During the night
16.In which direction do you fall most often?
Backwards
Forwards
Sidewardright / left (circle the correct answer)
Every direction as equeally often
17.What do you do to prevent falling?
Nothing
Avoid certain activities, like:…………………………………………………………….
The use of aids (e.g. a stick or a stroller)
Physiotherapy
Medication
Otherwise, namely.……………………………………………………………………….
18.Do you experience a fear of falling?
No
Slightly
Very much
19.Are there things you avoid because of this fear of falling?
No
Sometimes
Often
20.Can you give some examples of things you refrain from due to the fear of falling?
None
Household cores
Going outdoors to work or go shopping
Going outdoors for recreational activities
Doing sports
Otherwise namely.……………………………………………………………………….
21.How often do you go outdoors for pleasure?
Daily
Once a week
Not very often
Never
22.How often are you able to go outdoors independently?
Daily
Once a week
Not very often
Impossible
23.Do you have near falls? (This means that you lose your balance but retain your upright position, for instance by grabbing on to something)
No
Once a month
Once a week
Once a day
More than once a day
24.Does this near falling hamper you one or the other way?
No
It makes me more fearsome of falling
It makes me to avoid certain things
It makes me more fearsome of falling and makes me to avoid certain things
Otherwise namely.……………………………………………………………………….
25.Can you give an indication of your confidence in balance during daily activities on a scale of 0 up to 100 on the below mentioned scale? Zero means no confidence and 100 means full confidence in performing the activities?
0 100
1