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General Patient Fall Risk Assessment Template

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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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General Patient Fall Risk Assessment Template

Age

Is the patient older than 60?

Previous Falls

Is there one or more previous falls in the last few years?

Medication

Examine current medication

Four or more pills/medication (excluding vitamins)

Any psychotropic medication?

Vision

Review for glaucoma, cataracts, and appropriateness of spectacles.

Did you do a low contrast visual acuity test?

Peripheral Sensation

Check for diabetes.

Did you do a tactile sensitivity test (check if unable to feel 2 out of 3 trials)?

Strength/Reaction

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)

Completion

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: