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First Name

Last Name

Email

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Before starting, please list any medical conditions that significantly limit your walking or interfere with your daily activities.

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Who is Filling Out This Questionnaire?

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Q1. Have you had a fall in the past 12 months?

A. No

B. One fall

C. Two or more falls

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Q2. Do you use a cane, walker, or wheelchair to move around?

A. No

B. Sometimes (only for long walks)

C. Routinely / depend on it to move

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Q3. Do you have difficulty walking across a room without stopping, or need help to walk?

A. No difficulty

B. Some difficulty; slower or need occasional rest

C. Often need help or cannot walk without assistance

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Q4. Do you have weakness, numbness, “drop foot,” or reduced strength in legs/feet that affects walking?

A. No

B. Mild occasional problems

C. Frequent or obvious weakness affecting steps

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Q5. Do you have trouble climbing or descending stairs (without a stairlift)?

A. No, stairs are easy

B. Sometimes uneasy; need to hold rail

C. Avoid stairs or cannot use them safely

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Q6. Do you have vision problems that make it hard to see steps, obstacles, or floor-level changes even with glasses?

A. No

B. Mild trouble in dim light or at night

C. Frequent trouble seeing obstacles or uneven surfaces

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Q7. Do you take four or more prescription medications daily, or any medication that makes you dizzy or sleepy (including sedatives)?

A. No / fewer than 4 and none cause dizziness

B. 4+ meds but none cause dizziness/sedation

C. You take one or more medications that cause dizziness or sleepiness

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Q8. Do you feel unsteady when standing, or feel dizzy or lightheaded when you stand up?

A. Never

B. Occasionally

C. Frequently

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Q9. Do you have joint pain, arthritis, or limited range of motion that makes standing up, turning, or stepping difficult?

A. No

B. Mild occasional limitations

C. Major limitations that affect movement often

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Q10. Is your home environment full of tripping hazards (loose rugs, poor lighting, clutter) or do you lack handrails where needed?

A. No — home is mostly safe

B. Some hazards but manageable

C. Several hazards and no adaptations

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High Risk Of Falling

Your results indicate a high risk of falling. Follow up with a healthcare provider is recommended. An in‑home fall‑risk evaluation and participation in a personalized balance and strength training program are advised to help reduce fall risk.

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Low Risk Of Falling

Reach Out To Find Ways To Minimize Risk Of Falling; Improve Balance And Strength; Send Your Questions And Concerns To: Email

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Home Fall-Risk Assessment for Older Adults

High Risk Of Falling

Low Risk Of Falling

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