Sentara Health Plans

Take the fall risk assessment¹ below to find out your fall risk score and earn a Healthy Reward² of $15 while you’re at it.

Start by telling us who you are by completing all the fields below. This will ensure you receive your Healthy Reward.

Your Information

Note: Asterisk * indicates a required field

Form

First Name*

Last Name*

Sentara Medicare Member ID*

Can be found on your ID card

Secondary Member ID*

Box 1: Enter the first 9 numbers before the asterisk * on your member ID card.

Box 2: Enter the last 2 numbers after the asterisk * on your member ID card.

Phone Number*

Email Address*

Next, take the assessment by choosing yes or no to each statement:

I have fallen in the past year.*
People who have fallen once are likely to fall again. Yes (2) No (0)

I use or have been advised to use a cane or walker to get around safely.*
People who have been advised to use a cane or walker may already be more likely to fall. Yes (2) No (0)

Sometimes I feel unsteady when I am walking.*
Unsteadiness or needing support while walking are signs of poor balance. Yes (1) No (0)

I steady myself by holding onto furniture when walking at home.*
This is also a sign of poor balance. Yes (1) No (0)

I am worried about falling.*
People who are worried about falling are more likely to fall. Yes (1) No (0)

I need to push with my hands to stand up from a chair.*
This is a sign of weak leg muscles, a major reason for falling. Yes (1) No (0)

I have some trouble stepping up onto a curb.*
This is also a sign of weak leg muscles. Yes (1) No (0)

I often have to rush to the toilet.*
Rushing to the bathroom, especially at night, increases your chance of falling. Yes (1) No (0)

I have lost some feeling in my feet.*
Numbness in your feet can cause stumbles and lead to falls. Yes (1) No (0)

I take medicine that sometimes makes me feel light-headed or more tired than usual.*
Side effects from medicines can sometimes increase your chance of falling. Yes (1) No (0)

I take medicine to help me sleep or improve my mood.*
These medicines can sometimes increase your chance of falling. Yes (1) No (0)

I often feel sad or depressed.*
Symptoms of depression, such as not feeling well or feeling slowed down, are linked to falls. Yes (1) No (0)

Total:

¹The fall assessment was developed by the Greater Los Angeles VA Geriatric Research Education Clinical Center and affiliates and is a validated fall risk self-assessment tool (Rubenstein et al. J Safety Res; 2011: 42(6)493-499). Adapted with permission of the authors.

²Please allow 8–10 weeks to process your reward. Rewards cannot be used to buy tobacco or alcohol. Rewards cannot be converted to cash. You can only receive one reward per applicable service per plan year.

Fall Risk Assessment

Your Information