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First Name *
Last Name *
I have fallen in the past year
I use or have been advised to use a cane or walker to get around safely
Sometimes I feel unsteady when I am walking
I steady myself by holding onto furniture when walking at home
I am worried about falling
I need to push with my hands to stand up from a chair
I have some trouble stepping up onto a curb
I often have to rush to a toilet
I have lost some feeling in my feet
I take medicine that sometimes makes me feel light-headed or more tired than usual
I take medicine to help me sleep or improve my mood
I often feel sad or depressed
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    Rocky's Agency on Aging
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    MOW 2022
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    Head Start Logo
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    AmeriCorps Seniors
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