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Balance Self Test
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1.
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Have you fallen more than once in the past year?
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Yes
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No
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2.
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Do you take medicine for two or more of the following diseases: heart disease hypertension, arthritis, anxiety, and depression?
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Yes
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No
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3.
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Do you feel dizzy or unsteady if you make sudden changes in movement such as bending down or quickly turning?
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Yes
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No
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4.
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Do you have black-outs or seizures?
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Yes
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No
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5.
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Have you experienced a stroke or other neurological problem that has affected your balance?
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Yes
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No
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6.
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Do you experience numbness or loss of sensation in your legs and/or feet?
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Yes
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No
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7.
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Do you use a walker or wheel chair, or do you need assistance to get around?
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Yes
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No
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8.
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Are you inactive? (Answer yes if you do not participate in a regular form of exercise, such as walking or exercising 20-30 minutes at least three times a week.)
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Yes
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No
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9.
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Do you feel unsteady when you are walking, climbing stairs?
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Yes
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No
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10.
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Do you have difficulty sitting down or rising from a seated or lying position?
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Yes
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No
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