Name *(Required) E-mail *(Required) FALL PREVENTION SCREENING The purpose of this questionnaire is to determine if you are experiencing dizziness or unsteadiness as a recent injury. Please answer the following questions as it pertains to your dizziness or unsteadiness only. QUESTION Yes/No 1. Do you feel unsteady or dizzy? 2. Did you ever fall or feel like you were about to fall? 3. Are you dizzy or unsteady when you first get up? 4. Do you worry that you may fall or hurt yourself? 5. Does moving your head quickly make you dizzy? 6. Does bending over make you dizzy? 7. Does your dizziness or inbalance problem Interfere with your job or household duties? 8. Do you avoid outdoors for fear of falling? Name of Patient Date (mm/dd/yyyy) Enter Code Verification Code
