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?