Please circle “Yes” or “No” for each statement below.
  • People who have been advised to use a cane or walker may already be more likely to fall.
  • Unsteadiness or needing support while walking are signs of poor balance.
  • This is also a sign of poor balance.
  • People who are worried about falling are more likely to fall.
  • This is a sign of weak leg muscles, a major reason for falling.
  • This is also a sign of weak leg muscles
  • Rushing to the bathroom, especially at night, increases your chance of falling.
  • Numbness in your feet can cause stumbles and lead to falls.
  • Side effects from medicine can sometimes increase your chance of falling.
  • Side effects from medicine can sometimes increase your chance of falling.
  • Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls.
  • This field is for validation purposes and should be left unchanged.

This Site Does Not Provide Medical Advice

The site contents/materials are for information and educational purposes only and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it.

If you think you have a medical emergency, call your doctor or 911 immediately.

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; vol. 42, n°6, 2011, p. 493-499). Adapted with permission of the authors.

Are You at Risk for Falls?

Falls are the main reason why older people lose their independence.

  • Check your fall risk with the Staying Independent Checklist.
  • Use this checklist every year and discuss changes with your doctor.

More information:
Your local public health agency, champlainhealthline.ca or stopfalls.ca