This 'Staying Independent' resource was created by the Southwest Ontario Fall Prevention Network. SWOPN encourages you to complete the checklist and take it with you when you talk to your healthcare provider.
Staying Independent
Falls are the main reason adults lose their independence.
Complete the checklist below.
Take it with you when you talk to your healthcare provider
You can take control of your health
- Talk openly with your healthcare provider about your fall risks and what you can do.
- Ask your pharmacist to review your medications.
- Do an activity you enjoy.
- Begin an exercise program to improve your leg strength and balance.
- Have your eyes checked once a year.
- Remove clutter and tripping hazards.
For more information:
Contact your local health unit, community or senior centre for information on programs and services.
thehealthline.ca
211ontario.ca or call 211
fallpreventionmonth.ca
Instructions: Circle “Yes” or “No” for each statement below. Add up the total number of points for each “Yes” answer in the box.
|
Circle “Yes” or “No” |
Helpful Tips |
||
|---|---|---|---|
|
I have fallen in the past year. |
Yes (2) |
No (0) |
Learn more about reducing your fall risk, as people who have fallen are more likely to fall again. |
|
I use or have been advised to use a cane or walker to get around safely. |
Yes (2) |
No (0) |
Ask your doctor, a physiotherapist or occupational therapist about the most appropriate walking aid for your needs. |
|
Sometimes I feel unsteady when I am walking. |
Yes (2) |
No (0) |
Become more confident. Do activities and exercises that build strength and improve balance. |
|
I steady myself by holding onto furniture when walking at home. |
Yes (1) |
No (0) |
Do balance exercises every day. Remove items at home that might cause a trip or a slip. |
|
I am worried about falling. |
Yes (1) |
No (0) |
Reduce your fear. Stay active and follow these helpful tips to prevent falls. |
|
I need to push with my hands to stand up from a chair. |
Yes (1) |
No (0) |
Strengthen your muscles to reduce the chance of falling and being injured. |
|
I have some trouble stepping onto a curb. |
Yes (1) |
No (0) |
Do activities everyday that improve your strength and balance. |
|
I often have to rush to the toilet. |
Yes (1) |
No (0) |
Speak to your health care provider about ways to reduce the need to rush to the toilet. |
|
I have lost some feeling in my feet. |
Yes (1) |
No (0) |
Numbness in the feet can cause stumbles and falls. Talk with your doctor, podiatrist or chiropodist. |
|
I take medicine that sometimes makes me feel lightheaded or more |
Yes (1) |
No (0) |
As you age medication can affect you differently. Tell your doctor or pharmacist how you feel. |
|
I take medicine to help me sleep or improve my mood. |
Yes (1) |
No (0) |
Talk with your doctor or pharmacist about safer ways to get a good night’s sleep. |
|
I often feel sad or depressed. |
Yes (1) |
No (0) |
Talk with your doctor or health care provider about how you are feeling. Ask for help if you need it. |
|
IF you scored 4 points or more, you may be at risk for falling. Discuss |
TOTAL:_______ |
||
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; 2011: 42(6)493-499). Adapted with permission of the authors.