Risk for Falls Survey

Check Your Risk for Falling

Link to Falls Risk Survey from the CDC

Yes/No (Points) Statement Why it matters
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 chance 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 this brochure with your doctor

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