I have fallen in the past year (this includes sliding or slowly lowering yourself to the floor). *

Yes

No

I use or have been advised to use a cane or walker to get around safely. *

Yes

No

Sometimes I feel unsteady when I am walking. *

Yes

No

I steady myself by holding onto furniture when walking at home. *

Yes

No

I am worried about falling. *

Yes

No

I need to push with my hands to 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

First Name *

Last Name *

Email *

Phone *