NSR — Falls Risk — Patient Questionnaire
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Patient Information

Falls History

Number of falls in the past 12 months:
Fall circumstances — check all that apply:
Are you afraid of falling?

Short Falls Efficacy Scale — International (Short FES-I)

Instructions: Please tell us how concerned you are about the possibility of falling when doing each of the activities listed below. Think about how you usually do the activity. If you currently don't do the activity, answer based on how concerned you would be if you did it. Select one answer per activity — all 7 must be answered.
Cleaning the house (e.g., sweeping, vacuuming, dusting)
Getting dressed or undressed
Preparing simple meals
Taking a bath or shower
Going to the shop or running errands
Getting up from or sitting down in a chair
Going up or down stairs
🔒  CLINICIAN USE ONLY — Finalize and record the score below.

Source: Kempen GIJM et al. Age Ageing. 2008;37(1):45–50. © ProFaNE Consortium. Free for clinical use. MCID: 3 points. Score 7 = no concern; 28 = extreme concern. Cut-off ≥ 11 = clinically significant.

✓   End of Patient Questionnaire

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