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Bathroom Checklist Bedroom Checklist Living Areas Checklist Kitchen Checklist Hallways and Stairs Checklist Porch and Yard Checklist

Answer all 15 questions and press GO!

1. Have you fallen before? Were you injured when you fell?
Yes     No
2. Have you stopped doing any daily activities because you're afraid of falling? Do you avoid exercise because you're afraid of falling?
Yes     No
3. Has your hand strength decreased?
Yes     No
4. Has your eyesight diminished? Do you have trouble seeing depth or seeing at night?
Yes     No
5. Have you experienced hearing loss?
Yes     No
6. Do you have foot ulcers, bunions, hammertoes or callouses that hurt or cause you to adjust your steps?
Yes     No
7. Do you feel unsteady on your feet? Do you shuffle when you walk?
Yes     No
8. Do you feel weaker than you used to? Do you have less strength in your arms and legs?
Yes     No
9. Do you experience incontinence?
Yes     No
10. Do you feel dizzy when you stand up?
Yes     No
11. Do you take four or more medications? Do you take high blood pressure medications?
Yes     No
12. Do you take sleeping pills regularly?
Yes     No
13. Do you ever wear high heels?
Yes     No
14. Do your clothes (dresses, robes, etc) have long cords or ties?
Yes     No
15. Do you ever wear socks only, or slippers without rubber soles?
Yes     No