Fall Risk Self-Assessment | Aamra Seniors Club

For older adults & caregivers

I am completing this for:

Check every statement that applies. Leave statements unchecked if they do not apply. If you are unsure, discuss it with a healthcare professional.

An adapted educational self-check, not a validated clinical screening score or a diagnosis. It does not replace a healthcare professional’s assessment.

Mobility, Gait & Muscle Strength

Physical Balance

I have fallen in the past 12 months.A previous fall is an important predictor of future falls. (2 points)I need to use my arms to push myself up from a standard chair.May indicate reduced leg strength. (2 points)I use or have been advised to use a cane, walker, or furniture for support while walking.Holding furniture for support may indicate balance difficulties. (1 point)I sometimes feel unsteady or stumble when stepping off curbs or turning around.Unsteadiness is worth discussing with a healthcare professional. (1 point)

Medications, Dizziness & Sensory Health

Medical & Sensory

I take medicine to sleep, relax, or improve my mood (e.g., sleeping pills, anxiety meds, antidepressants).Some medicines can affect alertness and balance. Do not change medication without medical advice. (1 point)I feel dizzy, lightheaded, or faint when standing up quickly.This can be a sign of a drop in blood pressure on standing. (1 point)I take 4 or more prescription medications every day.A medication review can help identify interactions and side effects. (1 point)I have numbness, tingling, or reduced sensation in my feet or toes.Changes in sensation can affect balance. (1 point)I often have to rush to the bathroom urgently (especially in the dark or overnight).Urgency and poor lighting can increase nighttime fall hazards. (1 point)

Confidence & Fear of Falling

Psychological Drivers

I worry about falling, or I have cut back on walking, shopping, or seeing friends because of this fear.Avoiding activity can reduce muscle strength and confidence over time. (1 point)I wear bifocal, trifocal, or progressive glasses when walking outside or taking stairs.Multifocal lenses can affect step-edge perception. Discuss safe eyewear with an eye-care professional. (1 point)

Home Living Environment Audit

Environmental Safety

My home has throw rugs without non-slip backing, extension cords across walkways, or dim lighting in hallways/stairs.Removing trip hazards and improving lighting can make the home safer. (1 point)There are no grab bars firmly anchored inside the shower/bath or next to the toilet.Towel racks and shower doors are not designed to support body weight. (1 point)