Take Our Fall Risk Quiz

Fill this short form out if your client needs:

A 15 Minute Needs Snapshot

A Functional Capacity Evaluation (FCE)

Home Safety Modification / Assessment

Needs Assessment

Who is completing this Quiz? *

I am taking this quiz for myself

I am taking this quiz for someone else

First Name *

Last Name *

Phone *

Email *

Have you fallen in the past 12 months? *

Yes

Do you feel unsteady when walking or standing? *

Yes

Do you ever grab furniture or walls for balance around your home? *

Yes

Do you avoid certain activities because you’re worried about falling? *

Yes

Do your shoes, socks, or slippers ever cause you to slip or trip? *

Yes

Is your home lighting dim in hallways, bathrooms, or entryways? *

Yes

Do you need to push off a chair or use your hands to stand from sitting? *

Yes

Do you take 4 or more medications daily? *

Yes

Do you feel dizzy when you stand up quickly? *

Yes

Are there throw rugs, uneven surfaces, or cluttered walkways in your home? *

Yes

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

DRM Wellness

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