General Patient Fall Risk Assessment Template

• Patient's Name

• Conducted on (Date and Time)

  Date

• Nurse on duty

• Location
  Address

Age

• Patient age > 60 years?

  No

  Yes

Previous Falls

• One/more in the previous year

  No

  Yes

Medication

• Review current medication

• Four or more (excluding vitamins)

  No

  Yes

• Any psychotropic

  No

  Yes

Vision

• Examine for glaucoma, cataracts, and suitability of spectacles

• Low contrast visual acuity test

  No

  Yes

Peripheral Sensation

• Check for diabetes

• Tactile sensitivity test (Unable to feel 2 out of 3 trials)

  No

  Yes

Strength/Reaction

• Near tandem stand test (Unable to stand for 10 secs)

  No

  Yes

• Alternate step test (Unable to complete in 10 secs)

  No

  Yes

• Sit to stand test (Unable to complete in 12 secs)

  No

  Yes

Completion

• Refer to the scores above to get the Fall Risk Probability Rating:
  
  •Low: 1-2 risk factors
  •Medium: 3-5 risk factors
  •High: 6 and above risk factors

• Fall Risk Probability Rating:

  Low

  Medium

  High

• Recommendations

• Attending Nurse's Full Name and Signature

  Sign