Have you fallen in the past year? Yes No I use or have been advised to use a cane or walker to get around safely. Yes No Do you feel unsteady when standing or walking? Yes No I steady myself by holding onto furniture when walking at home. Yes No Do you worry about falling? Yes No Do you have to use your hands to push up when you stand up from a chair? Yes No I have some trouble stepping up onto a curb Yes No I often have to rush to the toilet. Yes No I have lost some feeling in my feet. Yes No I take medicine that sometimes makes me feel light-headed or more tired than usual. Yes No I take medicine to help me sleep or improve my mood. Yes No I often feel sad or depressed. Yes No ScoreYou are at a Low Risk of Falling You are at a High Risk of Falling Would you like a FREE Balance Screening? Yes No Enter your information below and we will contact you to schedule your free screening. What Clinic would you like to have your FREE Screening conducted at? Kosciusko Flowood Pearl Name First Last Email Phone
