This fall risk assessment template is used to evaluate a patient’s probability of falling. It includes fields to record a patient’s fall history, current medication, and medical test results (vision, peripheral sensation, and mobility). Record the patient’s fall risk rating depending on the number of accumulated risk factors. If a patient gets 1-2 risk factors patient has a Low risk probability of falling, a Medium risk for 3-5 risk factors and High risk for 6 risk factors and above.
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Patient age > 60 years?
One/more in the previous year
Review current medication
Four or more (excluding vitamins)
Examine for glaucoma, cataracts, and suitability of spectacles
Low contrast visual acuity test
Check for diabetes
Tactile sensitivity test (Unable to feel 2 out of 3 trials)
Near tandem stand test (Unable to stand for 10 secs)
Alternate step test (Unable to complete in 10 secs)
Sit to stand test (Unable to complete in 12 secs)
Refer to the scores above to get the Fall Risk Probability Rating:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to
take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment;
or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is
permissible in your workplace or jurisdiction.
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