Yes No

 Do you have a cat or dog?

 Do you need a cane or walker to keep your balance?

 Do you take three or more medications?

 Do you sometimes feel dizzy?

 Do you sometimes have to rush to the bathroom?

 Are the sidewalks in your neighbourhood cracked or uneven?

 Do you have trouble seeing clearly or difficulty concentrating?

 Do you have osteoporosis?

Yes No

 Do you have to get out of bed to reach a telephone or lamp?

 Do you drink alcohol frequently?

 Do you have to climb stairs to enter your home?

 Are there throw rugs or carpets that are not secured to the floor?

 Can you see phone or electrical cords loose on the floor?

 Does climbing stairs make you feel unsteady or out of breath?

 Do you have foot problems, weak muscles or stiff joints?