Please select "Yes" or "No" for each statement below
I have fallen in the last 6 months
I use or have been advised to use a cane or walkerto 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 a chair
I have some trouble stepping up onto a curb
I often have to rush to the toliet
I have lost some feeling in my feet
I take medicine that sometimes makes me feel lightheaded or more tired than usual
I take medicine to help me sleep or improve my mood
I often feel sad or depressed
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