Abilene Balance/Falls - Abilene Physical Therapy & Sports Rehab

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Balance/Falls Pre-Exam Form
Abilene Location

For patients experiencing balance difficulties and/or falls. Please fill out to the best of your ability and submit.

* Indicates required field

Name *

First

Last

PLEASE RATE YOUR PAIN LEVEL WITH ACTIVITY *

0 - No Pain 1 - Minimal - hardly noticeable 2-Mild - aware of pain but don't pay attention to it 3-Uncomfortable - bothers me but I can ignore it 4-Moderate - Constantly aware but can continue most activities 5-Distracting - Constantly aware and keeping me from doing some activities 6 - Distressing - Constantly aware of pain and I give up many activities. 7-Unmanageable - In pain all the time and unable to do most activities 8-Intense - Pain is so severe that it is hard to think of anything else. Talking & listening are difficult 9-Severe - My pain is all I can think about. I can barely talk or move because of it. 10-Unable to Move - In bed and can't move due to my pain. I need to go to the emergency room.

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 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. GETTING DRESSED AND UNDRESSED *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

2. PREPARE A SIMPLE MEAL *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

3. TAKE A BATH OR A SHOWER *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

4. GET IN/OUT OF CHAIR *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

5. GET IN/OUT OF BED *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

6. ANSWER THE DOOR OR TELEPHONE *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

7. WALK AROUND THE INSIDE OF YOUR HOUSE *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

8. REACH INTO CABINETS OR CLOSET *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

9. LIGHT HOUSEKEEPING *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

10. SIMPLE SHOPPING *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

USING PUBLIC TRANSPORTATION *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

12. CROSSING ROADS *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

LIGHT GARDENING OR HANGING OUT THE WASHING *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

Rate most commonly performed of these activities.

USING FRONT OR REAR STEPS AT HOME *

0 - Not Confident At All 1 2 3 4 5 - Fairly Confident 6 7 8 9 10 - Completely Confident

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now with 2 Locations to Better Serve You!

ABILENE:
103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8 a.m. - 5 p.m.

CHAPMAN:
1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Monday - Friday
8 a.m. - 5 p.m.

Physical Therapy
Other Services
Meet The Team
Testimonials
Patient Center
Contact
Insurance/Billing
Direct Access
Videos
FAQ
Career