Do you take more than two medications daily?

Yes / No

Have you or those around you noticed a change in your hearing?

Yes / No

Do you wear glasses or have any vision problems?

Yes / No

Have you fallen in the past year?

Yes / No

Do you have one or more of the following: Parkinson's disease, stroke, high blood pressure, urinary incontinence, osteoporosis, multiple sclerosis, or another neuromuscular disease?

Yes / No

Do you get dizzy when you get up, change position, or walk?

Yes / No

Do you have trouble picking up objects from the floor, reaching overhead, getting in and out of a chair, or walking without holding on to something?

Yes / No

Do you have throw rugs, stairs without rails, uneven surfaces, slippery floors, or cluttered walkways in your house?

Yes / No

Are you fearful of falling?

Yes / No

Do you wear shoes with high heels or slippery soles?

Yes / No

Do you have poor lighting conditions in your house?

Yes / No