Gender *

male

female

Have you had a fall or near fall in the past year?

Yes

No

Not sure

Do you have a fear of fall that restricts your activity?

Yes

No

Not sure

Do you have dizziness or a sensation of spinning when you lie down, tilt your head back, or roll over in bed?

Yes

No

Not sure

Do you feel uneasy or unsteady when walking down the aisle of a supermarket, or in an area congested with other people?

Yes

No

Not sure

Do you have difficulty walking in the dark, or on uneven surfaces such as gravel or a sloped sidewalk?

Yes

No

Not sure

Do your feet or toes frequently feel unusually hot or cold, numb or tingly?

Yes

No

Not sure

Do you wear bifocal or trifocal glasses, or is your vision notably better in one eye?

Yes

No

Not sure

Do you experience loss of balance, or a lightheaded/faint feeling when you stand up?

Yes

No

Not sure

Do you take medication for depression, anxiety, nerves, sleep or pain?

Yes

No

Not sure

Do you take four or more prescription medications daily?

Yes

No

Not sure

Do you feel like your feet just won’t go where you want them to go?

Yes

No

Not sure

Do you feel like you can’t walk a straight line, or are pulled to the side while walking?

Yes

No

Not sure

Has it been longer than six months since you participated in a regular exercise program?

Yes

No

Not sure

Do you feel that no one really understands how much dizziness and balance problems affect your quality of life?

Yes

No

Not sure

Are you interested in improving your balance and mobility?

Yes

No

Not sure