Fall Risk Assessment

Name*

First Last

Phone*

Email*

Have you fallen in the past 12 months?*

Does your fear of falling cause you to limit your activity level?*

Are you taking more than four medications a day?*

Do you suffer from dizzy spells or do you feel light-headed when you stand up?*

Do you use a cane or a walker to help you walk?*

Do you have any uncorrected visual impairments?*

Has there been a decrease in your functional ability in the last six months?*

Do you currently have any medical conditions that may contribute to falls?*

Does your home have loose rugs, cords, and/or clutter?*

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Phone

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