Table 3: Extrinsic and intrinsic risk factors of fall and their weighting based on current evidence
Question   Your Responses

Grading
(Nurse to complete score)
What is your age (years) and gender?   Female Male  
  less than 65 years less than 65 years [0]
  65-80 years 65-74 years [1]
  81-89 years more than 75 years [2]
  more than 90 years   [3]
         
Have you had any falls in the last 12 months?   None in 12 months [0]
  1 in the last 12 months [1]
  2-3 in the last 12 months [2]
  4 or more in the last 12 months [3]
         
Do you have any of the following conditions?   Stroke Number of conditions
  Parkinson's Disease  
  Arthritis nil [0]
  Dementia 1-2 [1]
  Heart condition 3-4 [2]
  Other conditions affecting your balance or walking >4 [3]
         
How many different types of medications do you take?   No medications [0]
  1-2 medications [1]
  3 medications [2]
  4 or more medications [3]
         
Do you have any difficulties with your eyesight or hearing?   No difficulty (does not limit activities at all) [0]
  Mild difficulty (mild limitation of activities) [1]
  Moderate difficulty (moderate limitation of activities) [2]
  Marked difficulty (markedly limits activities) [3]
         
Do you have any difficulties or unsteadiness when standing up, walking, or turning?   No difficulty or unsteadiness [0]
  Mild difficulty or unsteadiness [1]
  Moderate difficulty or unsteadiness [2]
  Marked difficulty or unsteadiness [3]