Falls Risk Self-Survey

Self-Survey for Falls Risk
Use the following questions to help determine if you or your loved one is at risk for falling. It is best to get help before you have a fall. If you have had one or more falls in the past month or experienced some of the below symptoms, it is very important to let your doctor know.

Problems with balance 
  • Do I get dizzy when I turn my head suddenly?
  • Do I ever fall back into my chair when attempting to stand?
  • Do I have a loss of sensation in my feet or legs?
  • Do I have problems with my vision?
  • Have I fallen more than once in the past year?
  • Do I feel unsteady when I walk?
Problems with muscle strength
  • Do I need to use my arms to assist as I get up from a chair?
  • Do I have difficulty rising up on my toes to reach objects overhead?
  • Have I ever sprained an ankle or broken a bone in my leg?
  • Do I walk with a limp or depend on one leg more than the other?
  • Do I fatigue easily after walking a few feet?

Problems with walking

  • Do I hold on to furniture as I walk through my home?
  • Do I sway or feel unsteady immediately after I stand up?
  • Do I shuffle my feet when I walk?
  • Can I walk household distances?
  • Do I need a cane or walker when I walk outside?
  • Am I able to cross the street at a traffic light before the light turns red?
  • Is it difficult to walk up a step?

Problems with low vision

  • Do I have difficulty focusing when I go from a bright place to a darker one?
  • Have I ever tripped or nearly fallen when I've gotten up to go to the bathroom at night?
  • Do I have difficulty seeing the edge of throw rugs or objects in my path?
  • Do I have difficulty seeing steps, stairs or curbs?
  • Do I keep the lights low or use low wattage bulbs to save electricity?
  • Have I had my eyes examined within the past year?

Problems with environmental risks

  • Are there throw rugs or loose floor coverings anywhere in the home?
  • Are electric cords, furniture or other objects in places where I could trip on them?
  • Are stair railings loose or only on one side of the staircase?
  • Are frequently used items in my kitchen hard to reach?
  • Is it dark when I get up at night to go to the bathroom?
  • Do I have trouble getting in and out of the bathtub/shower or on and off the toilet? 

Problems with medications and/or blood pressure

  • Do I take more than four different medications in a day?
  • Do I take medications without being aware of the purpose or potential side effects?
  • Do I skip prescribed medications or dosages?
  • Do I feel confused or sleepy after taking my medication?
  • Do I get dizzy or light-headed when I get up suddenly?

Individuals who are already patients of Holy Redeemer’s HomeCare program, automatically receive a comprehensive screening and evaluation, complete with recommendations and an action plan. However, this innovative screening and assessment program is open to anyone with a physician’s order, and, in some cases, verification of homebound status and insurance approval

For more information, please call 1-888-678-8678.

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