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STEADI- Check your risk for falling questionnaire

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Stay Healthy and On Your Feet Check your risk for falling Patient Name: Please circle "Yes" or "No" for each statement below. Why it matters 1. Yes (2) No (0) I have fallen in the past year. How many falls ? Were you injured? Y/ N People who have fallen once are likely to fall again. 2. Yes (1) No (0) Sometimes I feel unsteady when I am walking. Unsteadiness or needing support while walking are signs of poor balance. 3. Yes (1) No (0) I am worried about falling. People who are worried about falling are more likely to fall. If you answered 'Yes' to any of the above questions, please complete questions 4-12. 4. Yes (2) No (0) I use or have been advised to use a cane or walker to get around safely. People who have been advised to use a cane or walker may already be more likely to fall. 5. Yes (1) No (0) I steady myself by holding onto furniture when walking at home. This is also a sign of poor balance. 6. Yes (1) No (0) I need to push with my hands to stand up from a chair. This is a sign of weak leg muscles, a major reason for falling. 7. Yes (1) No (0) I have some trouble stepping up onto a curb. This is also a sign of weak leg muscles. 8. Yes (1) No (0) I often have to rush to the toilet. Rushing to the bathroom, especially at night, increases your chance of falling. 9. Yes (1) No (0) I have lost some feeling in my feet. Numbness in your feet can cause stumbles and lead to falls. 10. Yes (1) No (0) I take medicine that sometimes makes me feel light-headed or more tired than usual. Side effects from medicines can sometimes increase your chance of falling. 11. Yes (1) No (0) I take medicine to help me sleep or improve my mood. These medicines can sometimes increase your chance of falling. 12. Yes (1) No (0) I often feel sad or depressed. Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls. Total Add up the number of points for each "yes" answer. If you scored 4 points or more, you may be at risk for falling. Discuss this checklist with your health care provider. This checklist was developed by the Greater Los Angeles VA Geriatric Research Education Clinical Center and affiliates and is a validated fall risk self-assessment tool (Rubenstein et al. J Safety Res; 2011:42(6)493-499). Adapted with permission of the authors.

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