First name:

Last name:

Date of Birth (dd/mm/yyyy):
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If you answer yes to any of the following questions, you have an increased falls risk!

1. Have you recently had a fall? Yes No

2. Have you recently lost your balance? Yes No

3. Are you physically inactive (less than 30 minutes of physical activity per day)? Yes No

4. Do you have a neurological (e.g. stroke) or musculoskeletal condition that affects your balance? Yes No

5. Do you need a walking aid? Yes No

6. Do you require supervision or assistance with transfers or activities of daily living (ADL)? Yes No

7. Do you have problems with your vision? Yes No

8. Have you been confused, delirious or diagnosed with a cognitive disorder? Yes No

9. Do you have new onset or existing incontinence? Yes No

10. Are you taking multiple medications or medications that cause sedation? Yes No

11. Do you consume excessive amounts of alcohol or use illicit drugs? Yes No

12. Do you experience dizziness or light headedness when standing from a seated position or have a recent history of fainting? Yes No

13. Have you recently sustained a fracture from a minor bump or fall or have a history of osteoporosis? Yes No

14. Does your home environment have cluttered furniture, trip hazards, poor lighting, uneven/slippery surfaces, stairs or loose floor coverings? Yes No

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