Fall Risk Scoring

First Name *

Last Name *

Email Address *

Sitting to Standing *

Standing Unsupported *

Sitting with Back Unsupported but Feet Supported *

Standing to Sitting *

Transfers *

Standing Unsupported with Eyes Closed *

Standing Unsupported with Feet Together *

Reaching Forward with Arms Outstretched While Standing *

Pick Up Object From Floor From Standing Position *

Turning to Look Over Left and Right Shoulders While Standing *

Turn 360 Degrees *

Place Alternate Foot On Step or Stool While Standing Unsupported *

Standing Unsupported One Foot in Front *

Standing On One Leg *

Hearing Results

Vision Results

Refer to:

Brooks Rehabilitation

Palmer Chiropractic Clinic

Halifax Health - Ophthalmology

Atlantic Hearing

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