Have you fallen in the past year?
Yes
No
Do you feel unsteady when standing or walking?
Yes
No
Do you take medications that make you dizzy or drowsy?
Yes
No
Unsure
Do you have difficulty with balance or need support (e.g., cane, walker, furniture) when walking?
Yes
No
Do you have any vision problems or foot pain that affects your mobility?
Yes
No
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