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. Sometimes I feel unsteady when I am walking	1	2	3
4. I steady myself by holding onto furniture when walking at home	1	2	3
5. I am worried about falling	1	2	3
6. I need to push with my hands to stand up from a chair	1	2	3
7. I have trouble stepping up onto a curb	1	2	3
8. I often have to rush to the toilet	1	2	3
9. I have lost some feeling in my feet	1	2	3
10. I take medicine that sometimes makes me feel light-headed or more tired than usual	1	2	3
11. I take medicine to help me sleep or improve my mood	1	2	3
12. I often feel sad or depressed	1	2	3
Total the score	_____ +	_____ +	_____
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	_____

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.