Fall Prevention Screening Tool
Yes
No
Have you fallen in the past year?
Do you feel unsteady when walking?
Do you use a cane or walker?
Do you hold onto furniture when walking at home?
Do you need your hands to stand up from a chair?
Do you have trouble stepping up curbs or stairs?
Are you worried about falling?
Have you lost feeling in your feet (numbness/tingling)?
Do any medications make you dizzy or tired?
Do you rush to the bathroom often?
Calculation
✅ Low risk (0–2 YES)
Falls are not a normal part of aging — but they are preventable.
⚠️ Moderate risk (3–4 YES)
You may benefit from fall prevention strategies.
⚠️ Higher risk (5+ YES)
We recommend connecti
ng
with our Falls Prevention Program.
Would you be interested in joining the Fall Prevention Program?
Yes
No
Please enter your contact information below and a member of our staff will reach out.
First Name
MI
Last Name
Email
Phone
Contact Information