First Name
Last Name
Email
*
30 Second Sit to Stand
How many sit to stands did you complete?
*
1-9
10-14
15 or more
Split Squat
How many did split squats did you complete?
*
0
1-5
6 or more
Single Leg Balance
How long did you stand on your weaker leg for?
*
9 seconds or less
10-30 seconds
Over 30 seconds
10 Second Quick Step
How many did you complete on your weaker side?
*
5 or less
6-9
10 or more
Fall risk assessment total score