Risk for Falls Survey

Check Your Risk for Falling

Link to Falls Risk Survey from the CDC

Yes/No (Points)StatementWhy 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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