I have fallen in the last 6 months.
Yes     No 
I use or have been advised to use a cane or walker to get around safely.
Yes     No 
Sometimes I feel unsteady when I am walking.
Yes     No 
I steady myself by holding onto furniture when I walk.
Yes     No 
I am worried about falling.
Yes     No 
I need to push with my hands to stand up from a chair.
Yes     No 
I am often dizzy when I first stand up.
Yes     No 
I have trouble stepping up onto a curb.
Yes     No 
I often have to rush to the toilet.
Yes     No 
I have lost some feeling or have pain in my feet.
Yes     No 
I take medicine that sometimes makes me feel light-headed or more tired than usual.
Yes     No 
I take medicine to help me sleep or improve my mood.
Yes     No 
I often feel sad or depressed.
Yes     No