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) |
