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* 1. Are you losing confidence in your balance?

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* 2. Do you avoid going out as you're worried you might fall?

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* 3. Do you find yourself needing to plan ahead on how to best get across a room?

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* 4. Do you bump into things?

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* 5. Do you use a:

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* 6. If you thought that it might improve your balance and quality of life, would you be motivated to:

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* 7. Do you have any physical activity like to do?

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* 8. Do you have any special hobbies you like to do?

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* 9. Do you read:

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* 10. Do you regularly use:

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