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	Yes (2)	No (0)	People who have fallen once are likely to fall again
2. I use or have been advised to use a cane or walker to get around safely	Yes (2)	No (0)	3
3. Sometimes I feel unsteady when I am walking	Yes (1)	No (0)	3
4. I steady myself by holding onto furniture when walking at home	Yes (1)	No (0)	3
5. I am worried about falling	Yes (1)	No (0)	3
6. I need to push with my hands to stand up from a chair	Yes (1)	No (0)	3
7. I have trouble stepping up onto a curb	Yes (1)	No (0)	3
8. I often have to rush to the toilet	Yes (1)	No (0)	3
9. I have lost some feeling in my feet	Yes (1)	No (0)	3
10. I take medicine that sometimes makes me feel light-headed or more tired than usual	Yes (1)	No (0)	3
11. I take medicine to help me sleep or improve my mood	Yes (1)	No (0)	3
12. I often feel sad or depressed	Yes (1)	No (0)	3
	_____
Add up the number of points for each "yes" answer. If the score is 4 or more, there may be a risk for falling.	(Total Score)