Home Fall Risk Self Assessment

I am over age 65(Required)
I have three or more diagnosed conditions.(Required)
I often feel light-headed or dizzy when I stand up.(Required)
I have fallen at least one other time in the last three months.(Required)
I frequently have trouble making it to the bathroom or commode in time.(Required)
I have visual impairments and cannot see clearly, OR I have trouble with glare, OR I have trouble with my depth perception, OR I have trouble seeing things at night(Required)
I have trouble walking or transferring from a bed or a chair, OR I have arthritis, OR My coordination is impaired, OR I have pain in my legs or feet(Required)
My home is poorly lit, OR There is clutter in my home, OR My floor and rugs are uneven, OR I have trouble with getting in or out of the doors in my home(Required)
I take four or more medications, OR I take anti-depressants, sedatives, tranquilizers, blood pressure medication, steroids, cardiac medications, or other drugs that can make me dizzy(Required)
My pain sometimes or often makes me unsteady on my feet(Required)
I keep doing things that other people want me to stop doing, or I won't do what they want me to do(Required)
I seem to be more forgetful, or have more trouble concentrating(Required)
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