Risk factors | Question | |
Symptoms of falling (3 items) | 1. | In the past year, have you felt like you might fall down? |
2. | Have you often stumbled? | |
3. | Have you ever been told that you look like you might fall down? | |
Disease and physical symptoms (13 items) | 4. | Do you ever feel lightheaded upon standing up? |
5. | Do you ever feel dizzy upon standing up? | |
6. | Are you taking any medications, daily? | |
7. | Have you ever had a circulatory disease? | |
8. | Do you feel forgetful these days? | |
9. | Can you hear well (people talking, etc.)? | |
10. | Can you see well (newspaper, people's faces, etc.)? | |
11. | Do you ever feel groggy? | |
12. | Have you ever had a stroke? | |
13. | Do you have an articular disorder (ankle, knee, hip joint)? | |
14. | Do you have osteoporosis? | |
15. | Have you ever had complications from a disease? | |
16. | Have you ever been diagnosed as having diabetes? | |
Environment (4 items) | 17. | Are there slippery places in your house? |
18. | Are there obstacles that may cause someone to stumble in your house? | |
19. | Do you wear sandals or slippers a lot every day? | |
20. | Do your shoes fit your feet? | |
Behavior and character (8 items) | 21. | Do you often sit at home? |
22. | Do you hardly ever have occasions to go out? | |
23. | Do you have many occasions to go to the toilet at night? | |
24. | Do you act cautiously? | |
25. | Are you confident about not falling? | |
26. | Do you worry about falling? | |
27. | Do you often climb up the steep slope? | |
28. | Do you often rush about? | |
Physical function (22 items) | 29. | Are you strong enough to wring out a wet towel or cloth effectively? |
30. | Can you stand on one foot and put a sock on the other foot? | |
31. | Can you stand on one foot about 5 s? | |
32. | Do you usually use walking aids such as stick or walker? | |
33. | Do you feel your length of stride decrease? | |
34. | Do you feel your walking speed becoming slower? | |
35. | Can you walk continuously for about 1 km? | |
36. | Can you fold up and down a heavy futon? |