Fall Risk Screening Survey for Brookline Residents Aged 65+

This survey is being conducted by the Town of Brookline Public Health Department. The goal of the survey is to identify risks for falls in the older adult population, learn about previous falls and injuries, and to identify potential need for efforts to reduce falls in the community. The survey consists of 25 multiple choice questions and should only be completed by Brookline residents aged 65 and older. This information will be used internally by the health department to inform fall prevention interventions.  

Please only complete this survey one time. 

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How old are you? *
What is your primary language spoken at home? *
Do you live alone? *
Do you have friends and/or family that check in with you daily?  *
In comparison to other people your age, would you say that your health is:  *
Do you wear any type of emergency-alert bracelet or alarm? *
Have you been prescribed or asked by a medical professional to use any of these assistive devices? (Select all that apply) *
Required
If you reported being prescribed any assistive devices, how often do you use them?
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Have you been diagnosed with any visual impairments? *
Do you ever feel unsteady when walking? *
Do you worry about falling? *
Do you experience pain that affects your daily mobility (walking, household chores, climbing stairs)? *
Who organizes your daily medications? (by medications, we include both prescribed and over-the-counter medications) *
How many medications are you taking? (by medications, we include both prescribed and over-the-counter medications) *
Do you take medicine that sometimes makes you feel light-headed, dizzy, or more tired than usual?
Clear selection
Have you ever had your medications assessed by a pharmacist or doctor?
Clear selection
How many alcoholic drinks do you typically drink in a week? *
How often do you use marijuana or illicit drugs? *
How often do you feel lonely or isolated from those around you? *
Have you fallen or nearly fallen in the past year? *
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