Provena Life Connections is now part of Presence Health
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Fall Assessment

Are you or a loved one at risk for falling?  The possibility of a fall concerns most seniors and their families.  Falls are the most common cause of injury in the home for older adults and often lead to hospitalization.  To find out if the time is right to take steps to minimize your fall risk, answer the following 10 simple questions.

* Indicates required information
Have you fallen in the last 12 months? 

Do you often have difficulty seeing clearly? * 

When seated, do you have difficulty getting back up to a standing position? * 

When you stand up, do you sometimes feel lightheaded dizzy or off-balance? * 

Do you take four or more medications each day, including remedies from the health food or drug store? * 

Are you depressed, or do you feel "down" or "blue"? * 

Is it sometimes hard to walk because you feel stiff or weak or because your feet hurt? * 

Do you sometimes make frequent or hurried trips to the bathroom? * 

Do you limit your activities because you are afraid you might fall? * 

At home, is it sometimes difficult to move around safely because items you need are hard to reach or have to be carried down the stairs? * 

Name: * 
Address: * 
City: * 
Phone: * 
Email Address: 


Care @ Home
Presence Cor Mariae Center (Rockford)
Presence Fortin Villa Learning Center (Kankakee)
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The Greens of Elgin (Elgin)

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