Questionnaire to evaluate fall risk factors
1. I have fallen in the last 6 months.
2. I use or have been advised to use a cane or walker to get around safely.
3. Sometimes I feel unsteady when I am walking.
4. I steady myself by holding onto furniture when I walk.
5. I am worried about falling.
6. I need to push with my hands to stand up from a chair.
7. I am often dizzy when I first stand up.
8. I have trouble stepping up onto a curb.
9. I often have to rush to the toilet.
10. I have lost some feeling or have pain in my feet.
11. I take medicine that sometimes makes me feel light-headed or more tired than usual.
12. I take medicine to help me sleep or improve my mood.
13. I often feel sad or depressed.
Scoring Note: A score of 4 or lower (4 or more "Yes" responses) indicates potential fall risk and warrants further evaluation.