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)	People who have been advised to use a cane or walker may already be likely to fall
3. Sometimes I feel unsteady when I am walking	Yes (1)	No (0)	Unsteadiness or needing support while walking are signs of poor balance.
4. I steady myself by holding onto furniture when walking at home	Yes (1)	No (0)	This is also a sign of poor balance
5. I am worried about falling	Yes (1)	No (0)	People who are worried about falling are more likely to fall.
6. I need to push with my hands to stand up from a chair	Yes (1)	No (0)	This is a sign of weak leg muscles, a major reason for falling
7. I have trouble stepping up onto a curb	Yes (1)	No (0)	This is also a sign of weak leg muscles
8. I often have to rush to the toilet	Yes (1)	No (0)	Rushing to the bathroom, especially at night, increases the chance of falling
9. I have lost some feeling in my feet	Yes (1)	No (0)	Numbness in your feet can cause stumbles and lead to falls
10. I take medicine that sometimes makes me feel light-headed or more tired than usual	Yes (1)	No (0)	Side effects from medicine can sometimes increase the chance of falling
11. I take medicine to help me sleep or improve my mood	Yes (1)	No (0)	These medicines can sometimes increase the chance of falling.
12. I often feel sad or depressed	Yes (1)	No (0)	Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls.
	_____
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)