BALANCE ASSESSMENT | Tami Kobienia, PT

1. Have you fallen more than once in the past year?

Yes

No

2. Do you take medicine for two or more of the following diseases: heart disease, hypertension, arthritis, anxiety or depression?

Yes

No

3. Do you feel dizzy or unsteady if you make sudden changes in movement, such as bending down or turning quickly?

Yes

No

4. Do you have black outs or seizures?

Yes

No

5. Have you experienced a stroke or other neurological problem that has affected your balance?

Yes

No

6. Do you experience numbness or loss of sensation in your legs and/or feet?

Yes

No

7. Do you use a walker or wheelchair, or do you need assistance to get around?

Yes

No