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Have you fallen more than once in the past year?
Yes
No
Do you take medicine for two or more of the following diseases: heart disease, hypertension, arthritis, anxiety or depression?
Yes
No
Do you feel dizzy or unsteady if you make sudden changes in movement, such as bending down or turning quickly
Yes
No
Do you have black outs or seizures?
Yes
No
Have you experienced a stroke or other neurological problem that has affected your balance?
Yes
No
Do you experience numbness or loss of sensation in your legs and/or feet?
Yes
No
Do you use a walker or wheelchair, or do you need assistance to get around?
Yes
No

Balance Assessment

You may be at risk if you answer "yes" to one or more questions

Please note: If you think you have a balance problem, it is vital to talk to a physician

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