Survey Form - Test - Lori Michiel Fitness

Balance Profile Quiz

A survey to determine a person's risk of falling

This field is for validation purposes and should be left unchanged.

1. Do you sit more than three hours at a time?(Required)

If Yes, enter 5. If No, enter 0.

2. Can you stand on one leg for 10 seconds?(Required)

If Yes, enter 0. If No, enter 5.

3. Can you stand still with your feet together and your eyes closed for 10 seconds?(Required)

If Yes, enter 0. If No, enter 5.

4. Do you hesitate to walk for fear of tripping or falling?(Required)

If Yes, enter 5. If No enter 0.

5. Are you taking five or more medications a day?(Required)

If Yes, enter 5. If No, enter 0.

6. Can you take 10 steps with one foot directly in front of the other, in a straight line, without stumbling?(Required)

If Yes, enter 0. If No, enter 5.

7. Have you fallen or tripped in the last six months?(Required)

If Yes, enter 5. If No, enter 0.

8. Your age range: 45-64 / 65-79 / 80+(Required)

If you are 45-64 enter 0 / If you are 65-79 enter 5 / If you are 80+ enter 10

Enter your total score:(Required)

To receive your results, please enter your Name and Email. Your information is secure and only being used for the purpose of this survey. We do not sell or share your information.

Name(Required)

First

Email(Required)

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