Are You at Risk of Falling?

 

Complete this questionnaire to find out if you are at risk of falling.

Instructions:
Review the form below and keep track of your points:

  • Add up the number of points in parentheses for each "yes" response.
  • If you scored 4 points or more, you may be at risk for falling.
  • Discuss this test with your doctor to find ways to reduce your risk.

To open this questionnaire as an interactive PDF brochure, click here. Complete the form online, and then print it with your results.

 

 

 

 

 

 

 

 

 

 

 

Do you agree with this statement?

 

 

 

 

Actions You Can Take to Prevent Falls and Stay Independent

 

 

 

 

Yes (+2)

 

 

 

 

No (0)

 

 

 

 

I have fallen in the last 6 months.

 

 

 

 

Learn more on how to reduce your fall risk, as people who have fallen are more likely to fall again.

 

 

 

 

Yes (+2)

 

 

 

 

No (0)

 

 

 

 

I use or have been advised to use a cane or walker to get around safely.

 

 

 

 

Talk with a physiotherapist about the most appropriate walking aid for your needs.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

Sometimes, I feel unsteady when I am walking.

 

 

 

 

Exercise to build up your strength and improve your balance, as this is shown to reduce the risk for falls.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

I steady myself by holding onto furniture when walking at home.

 

 

 

 

Incorporate daily balance exercises and reduce home hazards that might cause a trip or slip.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

I am worried about falling.

 

 

 

 

Knowing how to prevent a fall can reduce fear and promote active living.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

I need to push with my hands to stand up from a chair.

 

 

 

 

Strengthening your muscles can reduce your risk of falling and being injured.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

I have some trouble stepping up onto a curb.

 

 

 

 

Daily exercise can help improve your strength and balance.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

I often have to rush to the toilet.

 

 

 

 

Talk with your doctor or incontinence specialist about solutions to decrease the need to rush to the toilet.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

I have lost some feeling in my feet.

 

 

 

 

Talk with your doctor or podiatrist, as numbness in the feet can cause stumbles and falls.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

I take medicine that sometime makes me feel light-headed or more tired than usual.

 

 

 

 

Talk with your doctor or pharmacist about medication side effects that may increase the risk of falls.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

I take medicine to help me sleep or improve my mood.

 

 

 

 

Talk with your doctor or pharmacist about safer alternatives for a good night’s sleep.

 

 

 

 

Yes (+1)

 

 

 

 

No (0)

 

 

 

 

I often feel sad or depressed.

 

 

 

 

Talk with your doctor about symptoms of depression, and help with finding positive solutions.

 

 

 

 

 

The above checklist was developed by the Greater Los Angeles VA Geriatric Research Education Clinical Center and affiliates and is a validated fall risk self-assessment tool (Vivrette, Rubenstein, Martin, Josephson & Kramer, 2011), and adapted with permission of J. Stevens, R. Vivrette, J. Kramer, & L. Rubenstein.