Fall risk assessment screener

1. 1

   I have fallen in the past year. 2 pts

   A previous fall is the single strongest predictor of a future fall.

   No Yes
2. 2

   I use, or have been advised to use, a cane or walker to get around safely. 2 pts

   Already using or being advised to use an assistive device signals known balance or strength concerns.

   No Yes
3. 3

   Sometimes I feel unsteady when I am walking.

   Subjective unsteadiness correlates with measured balance impairment.

   No Yes
4. 4

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

   Furniture-walking is a sign of impaired dynamic balance.

   No Yes
5. 5

   I am worried about falling.

   Fear of falling itself raises fall risk by changing gait and reducing activity.

   No Yes
6. 6

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

   Using arms to stand from a chair indicates lower-limb weakness.

   No Yes
7. 7

   I have some trouble stepping up onto a curb.

   Curbs require quad strength, balance, and step-height clearance — limitations here predict falls.

   No Yes
8. 8

   I often have to rush to the toilet.

   Urge incontinence and rushing to the toilet are well-established fall-risk triggers.

   No Yes
9. 9

   I have lost some feeling in my feet.

   Reduced foot sensation (often peripheral neuropathy) impairs balance and ground awareness.

   No Yes
10. 10

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

    Sedating or hypotensive medications are common contributors to falls.

    No Yes
11. 11

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

    Benzodiazepines, Z-drugs, and many antidepressants raise fall risk independently.

    No Yes
12. 12

    I often feel sad or depressed.

    Depression itself, and the medications used to treat it, both raise fall risk.

    No Yes

Educational reference only. Uses the CDC's Stay Independent 12-question questionnaire and the Timed Up-and-Go test, both validated for adults 65+. Not a clinical fall-risk evaluation. Talk with your doctor, physical therapist, or occupational therapist about your specific risk and prevention plan.