ABC Scale

* Denotes mandatory field

Client Name

First Name *

Last Name *

Date of Birth *

Please indicate your level of confidence doing each activity (below) without losing your balance or becoming unsteady by selecting the most relevant percentage point. Refer to the percentage rating scale to help you accurately indicate your confidence level.

Helpful Tip: if you currently don’t do one or more of the listed activities, imagine how confident you would beif you had to do the activity. If you currently use a walking aid or hold onto someone to do the activity, rate your confidence as it you were using these supports.

P lease contact clinic@orthomotion.com.au if you have any questions about completing this form.

Please indicate the conditions that apply to this outcome measure: *

Walking barefootWalking with shoesWalking with orthosis (AFO/brace/splint brace)

Specify *

Mobility aid (stick, crutch, walker etc)

Specify *

Additional information

Percentage Rating Scale

0%
No Confidence
10
20
30
40
50
60
70
80
90
100%
Completely Confident

0% = No confidence

100% = Completely confident

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

1. …walk around the house? *

2. …walk up or down stairs? *

3. …bend over and pick up a slipper from the 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 car park to the shops? *

11. …walk up or down a ramp? *

12. …walk in a crowded shopping centre where people rapidly walk past you? *

13. …are bumped into by people as you walk through a shopping centre? *

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 uneven ground? *

Total % *

Activity Based Confidence Score

Adapted from: Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol Med Sci 1995; 50(1): M28-34