Standard Quiz

Do you worry about falling?

Yes

No

Do you need to use your hands to help stand up from a chair?

Yes

No

Do any of your medications make you feel sleepy, lightheaded, or dizzy?

Yes

No

Have you stopped doing activities you enjoy because of fear of falling?

Yes

No

Are there areas of your home that are cluttered, poorly lit, or difficult to navigate?

Yes

No

Do you hold onto furniture, walls, or other objects when walking around your home?

Often

Sometimes

Rarely

Never

Do you use an assistive device?

Bed Bound

Chair Bound

Wheelchair

Walker

Rollator

Cane

None

One Fall Is Too Many. Let's Keep It That Way.