Arvada Fire Protection District

Welcome to our Falls Prevention Assessment and thank you for your participation! It will take just a few minutes to finish. Fill in your information below to get started.

Personal History

Have you experienced a fall in the last year?

Have you been injured as a result of a fall?

Personal Doctor

Do you visit your doctor annually?

Fall Prevention Classes

Have you attended a fall prevention class in the past year?

Exercise

Do you exercise normally (2-5 times per week)?

Fear of Falling

Do you have a fear of falling?

Medications

Do you take medications?

Your Home

Does your home environment have objects and/or spaces that may increase the risk of falling?

Assistive Devices

Do you use assistive devices to help balance or walk?

Your Health

Do health problems cause limitations that can increase your risk of falling?

Hearing and Vision

Do you have problems with hearing or vision?

Demographic Info

What is your name?

What is your zip code?

What is your Birth Year?

Are you?

Male
Female
Other

What is your Primary Language spoken in the home?