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Patient Fall Risk Assessment Template

Patient Fall Risk Assessment Template

This fall risk assessment template is used to assess a patient’s likelihood of falling.

Use this template
or download pdf
Patient Fall Risk Assessment Template

This fall risk assessment template is used to assess a patient’s likelihood of falling.

Use this template
or download pdf

About the Patient Fall Risk Assessment Template

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.

Related categories

  • Health and safety management templates
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  • Risk assessment templates
  • Safety templates
  • Workplace safety templates
Preview of the template
Audit
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 factors Medium: 3 to 5 risk factors High: 6 and more risk factors
Rate the fall risk probability:
Do you have any further recommendations?
Name and Signature of the attending nurse:
This template was downloaded 3 times

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Related resources

Access a complete set of resources aimed at maximizing safety, quality, and operational excellence, including detailed guides, related templates, and real-world use cases.

Template collections

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Risk for Falls Care Plan
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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.
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