Established Patient Questionnaire / Fall Risk Assessment

Patient Name

Date of Birth

1. Have there been any changes in your feet since your last evaluation?

Yes No

If yes, please describe

2. When was the last time you saw your primary care doctor?

3. Are you diabetic?

Yes (Type 1 or Type 2) No (Continue to #4)

What was your blood sugar this morning?

When is the last time you had your A1C Checked?

What was your result?

4. Do you have any current ulcers or history of ulcelrs?

Yes No

Fell two or more times.

Yes No

Was injured by fall that limited my regular activities for at least one day.

Yes No

Saw a doctor because I had a fall

Yes No

Found it to be hard to climb stairs or walk a short distance

Yes No

Had Trouble getting up from a soft chair.

Yes No

Have been unable to stand on one foot for 12 seconds without losing my balance.

Yes No

Trouble with my eyesight.

Yes No

Felt dizzy or lightheaded after a big meal.

Yes No

Took medication that caused me to feel dizzy or lightheaded.

Yes No

Took 9 or more different medications

Yes No

Have NOT had my vitamin D level in my blood checked.

Yes No

Danced, exercised, or practiced Tai Chi at least 3 times a week.

Yes No

Had my home checked for any dangers and modified as needed.

Yes No

Stopped some of my regular activities.

Yes No

Have been taking a calcium supplement regularly.

Yes No

If "Yes,” how much per day

Date Completed