Balance Self Test

1. Have you fallen more than once in the past year? *
Yes No

2. Do you take medication for two or more of the following diseases: heart disease, hypertension, arthritis, anxiety or depression? *
Yes No

3. Do you feel dizzy or unsteady if you make sudden changes in movement? *
Yes No

4. Have you had a joint replaced? *
Yes No

5. Have you experienced a stroke or another neurological problem that has affected your balance? *
Yes No

6. Do you experience numbness or loss of sensation in your legs and/or feet?*
Yes No

7. Do you use a walker or wheelchair, or do you need assistance to get around? *
Yes No

8. Do you feel unsteady when you are walking or climbing stairs? *
Yes No

9. Do you have difficulty sitting down or rising from a seated or lying position? *
Yes No

Are you at risk for falling?