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Fall Risk Assessment
I have fallen in the last year
Yes
No
1 / 10
I have been told to use a walker or a cane.
Yes
No
2 / 10
I lose my balance when I walk.
Yes
No
3 / 10
I have stopped doing things I enjoy because of a fear of falling.
Yes
No
4 / 10
I need to push off with both arms to get out of a chair.
Yes
No
5 / 10
If I am standing still, without holding onto anything, I sway.
Yes
No
6 / 10
I take short, narrow, steps when I walk.
Yes
No
7 / 10
I stumble or look at the ground when I walk.
Yes
No
8 / 10
I have lost feeling (peripheral neuropathy) in one or both feet.
Yes
No
9 / 10
My medication or blood pressure makes me feel sleepy or light-headed.
Yes
No
10 / 10
You scored a 0
Low Risk For Falls
Congratulations! You scored at a low risk for falls. This does not guarantee that you are not at risk. Ask your healthcare provider they think that you should be evaluated by a physical therapist. Remember, the CDC recommends a fall screening annually for seniors.
You scored a 5
Moderate Risk for Falls
You scored a moderate risk for falls. Based on your score it is highly recommended that you have a thorough balance assessment from a physical therapist who specializes in balance.
You scored a 9
High Risk for Falls
You scored a high risk for falls. Based on your score it is highly recommended that you have a thorough balance assessment from a physical therapist who specializes in balance.