Self Assessment

Take this short self-assessment to determine if you are at risk of a slip, trip, stumble or fall.

This assessment can then be printed and taken with you to your doctor or other health professional for further assessment. This should be done especially if you have answered yes to one or more questions or are unsure about any of the questions.

If you require this assessment in another language please scroll down the page for a link to another site where a similar questionnaire can be obtained.

Questionaire:

 

Question 1:

I have had at least one fall in the last 6 months

Question 2:

I am regularly taking sleeping tablets or tranquillisers or antidepressants

Question 3:

I am taking 4 or more prescription medications

Question 4:

I do less than 30 minutes of physical activity in a day (such as walking, house work, gardening, or bowls) on most days of the week

Question 5:

I have poor eyesight

Question 6:

It has been more than 12 months since my eyes were tested

Question 7:

I have, or previously have had one or more of the following:

  • Problems with my heart, blood pressure or circulation
  • A stroke
  • Diabetes
  • Parkinson's disease
  • Dizziness or funny turns
  • Having to rush to the toilet or incontinence
  • A recent major change in my health

Question 8:

I have difficulty getting up from a chair

Question 9:

I have poor balance when walking

Question 10:

I have either foot pain when walking and/or swelling and/or deformity of my feet