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.
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 factors
Medium: 3 to 5 risk factors
High: 6 and more risk factors
Please note that this checklist template is a hypothetical appuses-hero 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.
