Falls Quiz

1
Walking around the house...* This field is required.Please choose the option that best describes your confidence for walking around the house.
0% - no confidence to walk without falling
25% - able to walk short distances, very unsteady and likely to fall
50% - able to walk around most of the time, although quite unsteady
75% - able to walk around house most of the time, minor stumbles here or there
100% - able to walk around with full confidence all of the time, no stumbling
2
Walking up & down stairs...* This field is required.Please choose the option that best describes your confidence for walking up & down stairs.
0% - no confidence to walk up/down stairs falling
25% - able to navigate under 3 steps, fairly unsteady, needing high level of support
50% - able navigate up to 10 steps, requiring support
75% - able to navigate as many stairs required, needing some support
100% - able to navigate as many stairs required without needing support
3
Bending over to pick up a slipper/phone off the floor...* This field is required.In regard to picking any light object off the floor from a standing position.
0% - no confidence to do so without falling
25% - able to pick up off floor, very shaky & requiring support
50% - able to pick up off floor requiring support
75% - able to pick up off floor, shaky without support
100% - able to pick up off floor without needing support, no shakiness
4
Standing on your trip toes and reach for something overhead...* This field is required.In regard to reaching for light objects from overhead.
0% - no confidence to do so without falling
25% - able to do so, very shaky & requiring support
50% - able to do so, requiring support
75% - able to do so, minor shakiness without support
100% - able to do so without needing support, no shakiness
5
Standing on a small step stool...* This field is required.In regard to using a stable small step ladder or stool.
0% - no confidence to do so without falling
25% - able to do so, very shaky & requiring support
50% - able to do so, requiring support
75% - able to do so, some shakiness without support
100% - able to do so without needing support, no shakiness
6
Sweeping the floor...* This field is required.
0% - no confidence to do so without falling
25% - able to do so, very shaky & requiring support
50% - able to do so, requiring support
75% - able to do so, some shakiness without support
100% - able to do so without needing support, no shakiness
7
Walking outside the house to your car or to the gate...* This field is required.
0% - no confidence to do so without falling
25% - able to do so, very shaky & requiring support
50% - able to do so, requiring support
75% - able to do so, some shakiness without support
100% - able to do so without needing support, no shakiness
8
Getting in or out of your car...* This field is required.In regard to your, or a family member/carer's car.
0% - no confidence to do so without falling
25% - able to do so, very shaky & requiring support
50% - able to do so, requiring support
75% - able to do so, some shakiness without support
100% - able to do so without needing support, no shakiness
9
Walking across parking lot or shopping centre...* This field is required.
0% - no confidence to do so without falling
25% - able to do so, very shaky & requiring support
50% - able to do so, requiring support
75% - able to do so, some shakiness without support
100% - able to do so without needing support, no shakiness
10
Name* This field is required.Please enter your details to get your results
First Name
Last Name
11
Email* This field is required.
example@example.com
12
Phone Number* This field is required.
Please enter a valid phone number.
Should be Empty: