Please use and share this easy-to-use checklist (click on ‘read more’ below to view it) to assess your or your loved one’s fall risk. Call us at 1-800-HOMECARE (in MO) after you complete your assessment and we’ll arrange balance testing in your own home, paid for by Medicare. Prevent falls! Stay independent!



Phone Number:__________________________________


Are you at risk for falls?

Falls are a serious health concern related to many diseases, medical conditions or medications you may be taking.  Falls can result in serious injuries so we are taking proactive precautions to prevent them whenever possible.  To assist in identifying your level of risk for a fall, please complete the following questions.


Y          N         Have you fallen within the last 12 months?


Y          N         Have you had any dizziness or balance problems in the past year?


Y          N         Are you 60 years or older?


Y          N         Do you have diabetes?


Y          N         Do you require assistance to walk such as a cane or walker?


Y          N         Do you feel unsteady when you are walking or climbing stairs?


Y          N         Do you feel dizzy or unsteady if you bend down or turn quickly?


Y          N         Have you had a stroke in the past?


Y          N         Do you take medicine for high blood pressure, heart disease, arthritis or anxiety?


Y          N         Have you experienced black-outs or seizures?


If two or more of these statements apply to you, you may be at high risk for falls and may be a candidate for balance testing.

Physician’s Recommendation:

0 Low Risk for falls               0 High Risk for falls





Physician Signature                                           Date





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