Please Circle 'Yes' or 'No' for each Statement Below
I have fallen in the past year.
I used or have been advised to use a cane or walker to get around safely.
Sometimes I feel unsteady when I am walking.
I steady myself by holding onto furniture when walking at home.
I am worried about falling.
I need to push with my hands to stand up from the chair.
I have some trouble stepping up onto a curb.
I often have to rush to the toilet.
I have lost some feeling in my feet.
I take medicines that sometime s makes me feel light headed or more tired than usual.
I take medicines to help me sleep or improve my mood.
I often feel sad or depressed.
Add up the number of points for each yes answer.
If total score is 4 point or more then, patient needs to be evaluated for gait , strength & balance problems using Timed Up and Go (TUG) test.