Title Page

  • Patient's Name

  • Conducted on (Date and Time)

  • Nurse on duty

  • Location

Age

  • Patient age > 60 years?

Previous Falls

  • One/more in the previous year

Medication

  • Review current medication

  • Four or more (excluding vitamins)

  • Any psychotropic

Vision

  • Examine for glaucoma, cataracts, and suitability of spectacles

  • Low contrast visual acuity test

Peripheral Sensation

  • Check for diabetes

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

Strength/Reaction

  • 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)

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:

  • Recommendations

  • Attending Nurse's Full Name and Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.