Welcome to our Fall Risk Analysis form

We’re going to ask you a few questions to determine if you or a loved one may be a fall risk, so we can follow up with treatment recommendations.

First, are you answering for yourself or for a loved one?

For Myself

For a Loved One

What age group do you fall into?

Under 40 years old

40 to 50 years old

51 to 60 years old

61 to 70 years old

71 to 80 years old

Over 80 years old

While walking or getting up, have you felt unsteady or afraid that you might fall?

Do you use any of the following mobility aids?

Select all that apply.

A cane

A walker

A wheelchair

None of these

Which of the below symptoms are you experiencing?

Select all that apply.

Dizziness or lightheadedness

Blurry vision or impaired vision

Difficulty balancing

Fatigue or sleepiness

Numbness or pain in feet

Urinary incontinence

None of these

What symptoms of urinary incontinence do you experience?

Select all that apply.

Urine leaking when coughing, laughing, exercising, etc.

Suddenly needing to urinate

Experiencing involuntary leaks or urination regardless of activity

In the past year, how many times have you fallen?

Do you take any of the following medications on a regular basis?

Select all that apply.

Antidepressants or anti-anxiety medications

Blood pressure medication

Urinary incontinence medication

Allergy medications

Sleep medication

None of these

What age group does your loved one fall into?

Under 40 years old

40 to 50 years old

51 to 60 years old

61 to 70 years old

71 to 80 years old

Over 80 years old

While walking or getting up, have they seemed unsteady or have you been afraid that they might fall?

Do they use any of the following mobility aids?

Select all that apply.

No

A cane

A walker

A wheelchair

Which of the below symptoms have they experienced or talked about experiencing?

Select all that apply.

Dizziness or lightheadedness

Blurry vision or impaired vision

Difficulty balancing

Fatigue or sleepiness

Numbness or pain in feet

Urinary incontinence

None of these

I don't know

What symptoms of urinary incontinence have they been experiencing?

Select all that apply.

I don’t know

Urine leaking when coughing, laughing, exercising,etc.

Suddenly needing to urinate

Experiencing involuntary leaks or urination regardless of activity

In the past year, how many times have they fallen that you are aware of?

Do they take any of the following medications on a regular basis?

Select all that apply.

Antidepressants or anti-anxiety medications

Blood pressure medication

Urinary incontinence medication

Allergy medications

Sleep medication

None of these

I don’t know

Final Step

Lastly, please provide your contact information below so we can follow up with your analysis results:

Name*

Email Address*

Phone Number*

Comments

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