Key Questions to Identify Fall Risk:
1.)     Have you fallen in the past year?​
2.)     Are you afraid of falling?
3.)     Do you have unsteadiness/balance problems?
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If you have answered "yes" to any of these questions, you have a risk of falling. Further assessment is recommended.

General Health Questionnaire:
1.) Have you fallen in the past year?   ❑ Yes ❑ No

2.) Are you afraid of falling?  ❑ Yes ❑ No

3.) Do you use any assistive device to ambulate?    ❑ Yes ❑ No

4.) Do you ever feel dizzy or lightheaded?    ❑ Yes ❑ No

5.) Do you have trouble getting up from a chair?     ❑ Yes ❑ No  

6.) Do you have trouble stepping up or down curbs or steps?    ❑ Yes ❑ No

7.) Do you need to steady yourself by leaning on someone/something?  ❑ Yes ❑ No

8.) Do you see well: during the day/at night?     ❑ Yes ❑ No

9.) Do you have Diabetes?    ❑ Yes ❑ No

10.) Do you have blood pressure issues? ❑ Yes ❑ No

11.) Do you have arthritis/painful joints? ❑ Yes ❑ No

12.) Do you have Parkinson’s disease/had a stroke?    ❑ Yes ❑ No  
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13. Do you have unsteadiness/balance problems?    ❑ Yes ❑ No  

14.) Do you take any medications?    ❑ Yes ❑ No

15.) Have you had seizures in the past?  ❑ Yes ❑ No

16.) Did you have hip replacement done in the past year?  ❑ Yes ❑ No

Consult an appropriate healthcare professional to resolve risk factors related to falls.