| Yes (2) |
No (0) |
I have fallen in the past year. |
People who have fallen once are likely to fall again. |
| Yes (2) |
No (0) |
I use or have been advised to use a cane or walker to get around safely. |
People who have been advised to use a cane or walker may already be more likely to fall. |
| Yes (1) |
No (0) |
Sometimes I feel unsteady when I am walking. |
Unsteadiness or needing support while walking are signs of poor balance. |
| Yes (1) |
No (0) |
I steady myself by holding onto furniture when walking at home. |
This is also a sign of poor balance. |
| Yes (1) |
No (0) |
I am worried about falling. |
People who are worried about falling are more likely to fall. |
| Yes (1) |
No (0) |
I need to push with my hands to stand up from a chair. |
This is a sign of weak leg muscles, a major reason for falling. |
| Yes (1) |
No (0) |
I have some trouble stepping up onto a curb. |
This is also a sign of weak leg muscles. |
| Yes (1) |
No (0) |
I often have to rush to the toilet. |
Rushing to the bathroom, especially at night, increases your chances of falling. |
| Yes (1) |
No (0) |
I have lost some feeling in my feet. |
Numbness in your feet can cause stumbles and lead to falls. |
| Yes (1) |
No (0) |
I take medicine that sometimes makes me feel light-headed or more tired than usual. |
Side effects from medicines can sometimes increase your chance of falling. |
| Yes (1) |
No (0) |
I take medicine to help me sleep or improve my mood. |
These medicines can sometimes increase your chance of falling. |
| Yes (1) |
No (0) |
I often feel sad or depressed. |
Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls. |
| Total _____________ |
Add up the number of points for each "yes" answer. If you scored 4 points or more, you may be at risk for falling. Discuss with brochure with your doctor. |