1 in 4 adults 65+ fall in America every year. Here in the Mid-South, falls are the third leading cause of admissions to the Elvis Presley Memorial Trauma Center at Regional One Health.

Are YOU at risk of falling?

This questionnaire is 18 questions and 2 pages long and will take around 5 minutes to complete.

These questions are adapted from the Centers for Disease Control and Prevention's "Stay Independent" publication as a part of their "STopping Elderly Accidents, Deaths, and Injuries" (STEADI) program.

More information about STEADI can be found HERE.

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* What is your home's ZIP code?

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* How many people live in your home?

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* How many people 65 years of age or older live in your home?

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* How many people 17 years of age or younger live in your home?

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* I have fallen in the past year.

Yes

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* I use or have been advised to use a cane or walker to get around safely.

Yes

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* Sometimes I feel unsteady when I am walking.

Yes

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* I steady myself by holding onto furniture when I am walking.

Yes

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* I am worried about falling.

Yes

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* I need to push with my hands to stand up from a chair.

Yes

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* I have some trouble stepping up onto a curb.

Yes

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* I often have to rush to the toilet.

Yes

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* I have lost some feeling in my feet.

Yes

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* I take medicine that sometimes makes me feel light-headed or more tired than usual.

Yes

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* I take medicine to help me sleep or improve my mood.

Yes

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* I often feel sad or depressed.

Yes

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* Do you have a relationship with a primary care provider (physician/doctor, nurse practitioner, or regular community health clinic)?

Yes