Fall Risk Assessment Checklist Template

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Fall Risk Assessment Tool
Resident: _______________________________________
Home: _____________________
Category
Value
Resident status
Score
History of falls in
No falls
0
1-2 falls
1
past 3 months
2
3 or more falls
(Choose one)
Ambulation
0
Independent
Non-ambulatory
1
(May choose more than
Unable to get up from sitting position
2
one)
without assistance
Full assist required
3
Gait/Balance
0
Normal
Unsteady at times
1
(Choose one)
Requires assistive device
2
Independently propels w/c
3
Sleep Patterns
0
Normal
1
Sleeps less than 6 hours a night
(Choose one)
Sleeps less than 4 hours a night
2
Vision
0
Adequate with or without glasses
Poor
2
(Choose one)
Blind
4
Oriented times three
Mental Status
0
2
Intermittent confusion
(Choose one)
4
Disoriented times three
Takes 1-2 medications daily
Medications
2
3
Takes 2-9 medications daily
(May choose more than
4
Take 9+ medications daily
one)
3
Takes psychotropic medications
Adaptive
No adaptive equipment needed
0
Orthotic Shoes
1
Equipment
AFO’s
(May choose more than
1
one)
Cane
2
Walker
2
Wheelchair
2
Arthritis/Osteoporosis
Chronic Medical
1
1
Cerebral Palsy
Conditions
1
Diabetes
(May choose more than
1
Dementia
one)
Peripheral Neuropathy
1
Cardiac Condition
1
Hemiplegia
2
2
Extremity contractures/fractures
2
H/O Stroke/TIA
2
Seizure activity within the past 12 months
Total Score: ___________________
Fall Risk Assessment Tool
Resident: _______________________________________
Home: _____________________
Category
Value
Resident status
Score
History of falls in
No falls
0
1-2 falls
1
past 3 months
2
3 or more falls
(Choose one)
Ambulation
0
Independent
Non-ambulatory
1
(May choose more than
Unable to get up from sitting position
2
one)
without assistance
Full assist required
3
Gait/Balance
0
Normal
Unsteady at times
1
(Choose one)
Requires assistive device
2
Independently propels w/c
3
Sleep Patterns
0
Normal
1
Sleeps less than 6 hours a night
(Choose one)
Sleeps less than 4 hours a night
2
Vision
0
Adequate with or without glasses
Poor
2
(Choose one)
Blind
4
Oriented times three
Mental Status
0
2
Intermittent confusion
(Choose one)
4
Disoriented times three
Takes 1-2 medications daily
Medications
2
3
Takes 2-9 medications daily
(May choose more than
4
Take 9+ medications daily
one)
3
Takes psychotropic medications
Adaptive
No adaptive equipment needed
0
Orthotic Shoes
1
Equipment
AFO’s
(May choose more than
1
one)
Cane
2
Walker
2
Wheelchair
2
Arthritis/Osteoporosis
Chronic Medical
1
1
Cerebral Palsy
Conditions
1
Diabetes
(May choose more than
1
Dementia
one)
Peripheral Neuropathy
1
Cardiac Condition
1
Hemiplegia
2
2
Extremity contractures/fractures
2
H/O Stroke/TIA
2
Seizure activity within the past 12 months
Total Score: ___________________
Fall Risk Assessment Tool
Results of Fall Risk Assessment
Total score less than 8 (Minimal fall risk)
A score of less than 8 is identified as a minimal fall risk. This person is at low risk for chronic
falls and no extra precautionary measures are needed.
Total score of 9-12 (Moderate fall risk)
A person with a score of 9-12 points is identified as a moderate fall risk and should be evaluated
by Physical Therapy or other medical professional to assess need for fall precautions.
Score of 13+ (Severe fall risk)
A person with a score of greater than 13 is identified as a severe fall risk and should be evaluated
by Physical Therapy immediately for necessary precautions. If precautions are already in place
they should be addressed in the IP.
Reason for completing assessment:
Admission to the facility
Annual IP
Medication change with side effect of change in mental status (To be completed within
30 days of start of new medication) Medication Change: ________________________
Hospitalization greater than 3 days
New diagnosis that could increase risk of falls
Change in adaptive equipment needs
Vision changes
Fracture
Other
Results of assessment:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Recommendations:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Safety measures already in place:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Person completing assessment: __________________________________________________
Date:_______________________________
Fall Risk Assessment Tool

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