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What is your full name?
What is your date of birth?
Answer option for these questions: Yes or No
Right now, are you feeling weak, dizzy, or lightheaded?
Have you fallen in the past 3 months?
Do you need assistance to walk?
Do you need a cane?
Do you need crutches?
Do you need a walker?
Do you need a wheelchair?
Do you need a companion to help you?
Do you have a fear of falling?
Have you taken or will you take any medications for anxiety to help you with this exam today?