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Falls in the past Y:Hx:1Y:^Patient:Ord:
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Use AndOr advised cane or walker
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Sometimes feel unsteady when walking
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Use furniture to steady when walking
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Worried about falling
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Push with hands to stand up from chair
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Trouble stepping up onto curb
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Often rush to toilet
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Loss of feeling in feet
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Med causes light-headedness or fatigue
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Taking medicine for sleep or mood
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Often feel depressed
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Stay Independent total score:Score:Pt:^Patient:Qn:Stay Independent
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{score}
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