Staying Independent Checklist –
Check Your Risk for Falling
Did you know?
Falls are the leading cause of injury among older adults in Canada:
· 20- 30% experience at least one fall each year
· 95% of all hip fractures are due to a fall
· 50% of all falls causing hospitalization happen at home
Falls can result in chronic pain, reduced mobility, loss of
independence and even death.
(Public Health Agency of Canada, 2014)
The Staying Independent Checklist is a self-screening tool
for older adults to find out if they are at risk for falling.. Older
\adults are encouraged to complete the Checklist and to
follow-up with their healthcare provider as needed.
For more information or to get your copy of the Staying
Independent Checklist, please call the Ottawa Public
\Health Information Line at 613-580-6744
OR VIEW BELOW
This checklist was developed by the Greater Los Angeles VA Geriatric Research Education Clinical Center and affiliates and is a validated fall risk self-assessment tool
(Rubenstein et al. J Safety Res; vol. 42, n°6, 2011, p. 493-499). Adapted with permission of the authors.
Check Your Risk for Falling
Primary Care Providers: For more information about the Champlain Falls Prevention Strategy, the Staying Independent
Checklist, and the clinical algorithm go to: stopfalls.ca
Please circle “Yes” or “No” for each statement below. Why it matters
Yes (2) No (0) I have fallen in the last 6 months. People who have fallen once are likely
to fall again.
Yes (2) No (0) I use or have been advised to use a cane or
walker to get around safely.
People who have been advised to use
a cane or walker may already be more
likely to fall.
Yes (1) No (0) Sometimes I feel unsteady when I am walking.
Unsteadiness or needing support
while walking are signs of poor
Yes (1) No (0) I steady myself by holding onto furniture when
walking at home. This is also a sign of poor balance.
Yes (1) No (0) I am worried about falling. People who are worried about falling
are more likely to fall.
Yes (1) No (0) I need to push with my hands to stand up from a
This is a sign of weak leg muscles, a
major reason for falling.
Yes (1) No (0) I have some trouble stepping up onto a curb. This is also a sign of weak leg
Yes (1) No (0) I often have to rush to the toilet. Rushing to the bathroom, especially at
night, increases your chance of falling.
Yes (1) No (0) I have lost some feeling in my feet. Numbness in your feet can cause
stumbles and lead to falls.
Yes (1) No (0) I take medicine that sometimes makes me feel
light-headed or more tired than usual.
Side effects from medicine can
sometimes increase your chance of
Yes (1) No (0) I take medicine to help me sleep or improve my
These medicines can sometimes
increase your chance of falling.
Yes (1) No (0) I often feel sad or depressed.
Symptoms of depression, such as not
feeling well or feeling slowed down,
are linked to falls.
Add up the number of points for each “yes” answer.
If you scored 4 points or more, you may be at risk for falling.
Discuss this brochure with your doctor or health care practitioner.
Falls are the main reason
why older people lose their
Are you at risk?
For more information on exercise and
falls prevention programs, contact
Champlain CCAC (613 310-2222 or
This initiative is sponsored by the Champlain Local
Health Integration Network and the four regional