Our Mission is to Stop Falls! But, How?

1. I have fallen in the past year.

• Yes
• No

2. I use or have been advised to use a cane or walker to get around safely.

• Yes
• No

3. Sometimes I feel unsteady when I am walking.

• Yes
• No

4. I steady myself by holding onto furniture when walking at home.

• Yes
• No

5. I am worried about falling.

• Yes
• No

6. I need to push with my hands to stand up from a chair.

• Yes
• No

7. I have some trouble stepping up onto a curb.

• Yes
• No

8. I often have to rush to the toilet.

• Yes
• No

9. I have lost some feeling in my feet.

• Yes
• No

10. I take medicine that sometimes makes me feel light-headed or more tired than usual.

• Yes
• No

11. I take medicine to help me sleep or improve my mood.

• Yes
• No

12. I often feel sad or depressed.

• Yes
• No