What’s your fall risk?

To help determine your risk of falling, you should consult your primary care provider at least once a year.

Before your visit, complete the Staying Independent Checklist to assess your own risk.

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Just answer 12 quick questions with “Yes” or “No.”

Your responses are anonymous—no personal data is stored or recorded.

Step 1 of 12

I have fallen in the past 6 months.(Required)

People who have fallen once are likely to fall again.

Yes

I use or have been advised to use a cane or walker to get around safely.(Required)

People who have been advised to use a cane or walker may already be more likely to fall.

Yes

Sometimes I feel unsteady when I am walking.(Required)

Unsteadiness or needing support while walking are signs of poor balance.

Yes

I steady myself by holding onto furniture when walking at home.(Required)

This is also a sign of poor balance.

Yes

I am worried about falling.(Required)

People who are worried about falling are more likely to fall.

Yes

I need to push with my hands to stand up from a chair.(Required)

Strengthening your leg muscles can reduce your risk of falling and being injured.

Yes

I have some trouble stepping up onto a curb.(Required)

This is also a sign of weak leg muscles.

Yes

I often have to rush to the toilet.(Required)

Rushing to the bathroom, especially at night, increases your chance of falling.

Yes

I have lost some feeling in my feet.(Required)

Numbness in your feet can cause stumbles and lead to falls.

Yes

I take medicine that sometimes makes me feel light-headed or more tired than usual.(Required)

Side effects from medicines can sometimes increase your chance of falling.

Yes

I take medicine to help me sleep or improve my mood.(Required)

These medicines can sometimes increase your chance of falling.

Yes

I often feel sad or depressed.(Required)

Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls.

Yes

Bring this self-screening checklist to your primary care provider to help guide the discussion about your personal risk factors.

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