Please complete this questionnaire to determine your risk of falling. When you know your risk, you can take steps to improve or alleviate the factors that could cause you to fall and injure yourself.

Answer Yes or No to the following questions.

Why it matters: People who have fallen once are likely to fall again.
Why it matters: People who have been advised to use a cane or walker may already be more likely to fall.
Why it matters: Unsteadiness or needing support while walking are signs of poor balance.
Why it matters: This is also a sign of poor balance.
Why it matters: People who are worried about falling are more likely to fall.
Why it matters: This is a sign of weak leg muscles, a major reason for falling.
Why it matters: This is also a sign of weak leg muscles.
Why it matters: Rushing to the bathroom, especially at night, increases your chance of falling.
Why it matters: Numbness in your feet can cause stumbles and lead to falls.
Why it matters: Side effects from medicines can sometimes increase your chance of falling.
Why it matters: These medicines can sometimes increase your chance of falling.
Why it matters: Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls.

Based on your responses above, you may be at risk for falling. Please fill out the fields below for more information about how we can help.