Falls Risk Assessment Survey
Please answer the following questions to help assess your risk of falling.
Age Group
*
Please Select
Under 50
50-64
65-74
75-84
85 and above
Do you use any assistive devices for mobility?
*
Yes
No
Have you experienced any falls in the past 12 months?
*
Yes
No
Do you have any balance or gait problems?
*
Yes
No
Do you take any medications that may cause dizziness or drowsiness?
*
Yes
No
Do you have any vision problems that affect your daily activities?
*
Yes
No
Do you have any chronic health conditions?
*
Yes
No
Please provide any additional comments or concerns regarding your risk of falling.
Submit
Should be Empty: