I have fallen in the past year.
I use or have been advised to use a cane or walker to get around safely.
Sometimes I feel unsteady when I am walking.
I steady myself by holding onto furniture when walking at home.
I am worried about falling.
I need to push with my hands to stand up from a chair.
I have some trouble stepping up onto a curb.
I often have to rush to the toilet.
I have lost some feeling in my feet.
I take medicine that sometimes makes me feel light-headed or more tired than usual.
I take medicine to help me sleep or improve my mood.
I often feel sad or depressed.
This checklist was developed by the Greater Los Angeles VA Geriatric Research Education Clinical Center and affiliates and is a validated fall risk self-assessment tool (Rubenstein et al. J Safety Res; 2011: 42(6)493-499). Adapted with permission of the authors.
