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Fall Risk Assessment
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Patient Health Questionnaire - Depression Screening
Fall Risk Assessment
First Name
*
Middle Initial
Last Name
*
Date of Birth
*
How many times have you fallen in the last 12 months?
*
None
Once without injury
Once with injury
2 or more times
Do you feel unsteady when standing or walking?
Yes
No
Do you worry about falling?
Yes
No
How do you stand from a chair?
I stand straight up
I push up once
I push up 2 or more times
I require assistance to stand
Do you use a mobility device?
No
Cane
Walker
Wheelchair
Check all that apply
* Required field
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