This fall risk assessment template is used to assess a patient’s likelihood of falling. It covers fields to register a patient’s fall history, current medication, and medical test results. Document the patient’s fall risk rating depending on the number of collected risk factors. If a patient gets 1 to 2 risk factors patient has a low risk likelihood of falling, a medium risk for 3 to 5 risk factors and a high risk for 6 risk factors and above.
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Is there one or more previous falls in the last few years?
Examine current medication
Four or more pills/medication (excluding vitamins)
Any psychotropic medication?
Review for glaucoma, cataracts, and appropriateness of spectacles.
Did you do a low contrast visual acuity test?
Check for diabetes.
Did you do a tactile sensitivity test (check if unable to feel 2 out of 3 trials)?
Sit to stand test (not able to complete in 12 seconds)
Near tandem stand test (Not able to stand for more than 10 secs)
Alternate step test (not able to finish in 10 seconds)
Refer to the scores discussed above to get the fall risk probability rating: Low: 1 to 2 risk factorsMedium: 3 to 5 risk factorsHigh: 6 and more risk factors
Rate the fall risk probability:
Do you have any further recommendations?
Name and Signature of the attending nurse:
Please note that this checklist template is a hypothetical example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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