Fall Risk
From Patient Determinants
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) | 3 |
| 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) |
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.
