Fall Risk

This is a Fall Risk Questionnaire to determine the risk for falls. With a score 4 points or higher, there may be a risk for falling.

Return to the CDC Health Risk Assessments or Patient Well-Being Assessment

			Why it matters
1. I have fallen in the last 12 months	1	2	3
2. I use or have been advised to use a cane or walker to get around safely	1	2	3
3. Trouble failing asleep, or sleeping too much	1	2	3
4. Feeling tired or having little energy	1	2	3
5. Poor appetite or overeating	1	2	3
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down	1	2	3
7. Trouble concentrating on things, such as reading the newspaper or watching television	1	2	3
8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual	1	2	3
9. Thoughts that you would be better off dead or of hurting yourself in some way	1	2	3
Total the score	_____ +	_____ +	_____
		=Total Score	_____

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
□ Not difficult at all
□ Somewhat difficult
□ Very difficult
□ Extremely difficult

Interpreting PHQ-9 Scores

Diagnosis	Total Score	For Score	Suggested Action
Minimal depression	0-4	≤ 4	The score suggests the patient may not need depression treatment
Mild depression Moderate depression	5-9 10-14	5-14	Physician uses clinical judgement about treatment, based on patient's duration of symptoms and functional impairment
Moderately severe depression Severe depression	15-19 20-27	> 14	Warrants treatment for depression, using antidepressant, psychotherapy and/or combination of treatment

The PHQ-9 is described in more detail at the Pfizer website.