Minnesota Safety Council: Fall Prevention 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