Balance Self-Assessment Form
A simple evaluation form to help patients and families assess fall risk and balance impairment independently at home.
What is inside this form?
This form helps identify fall risk and balance impairment that may need follow-up:
- Fall history questionnaire: frequency, circumstances, and locations of falls
- Single-leg standing test: instructions and simple result interpretation
- Fear of falling scale: the ABC (Activities-specific Balance Confidence) scale
- Home environment checklist: risk factors in the bathroom, stairways, and bedroom
- Follow-up table: when to seek medical evaluation promptly
The completed form can be brought to a medical appointment to support clinical assessment.