FALL RISK ASSESSMENT
Client Name:
DOB:
Instructions: On admission, after a fall and regular intervals per facility policy. Assess the participant
status in the eight clinical condition parameters listed below (A-H) by assigning the corresponding
score that best describes the participant in the appropriate assessment column. Add the columns of
numbers to obtain the TOTAL SCORE. If this score is 10 or greater, the participant should be considered
at HIGH RISK for potential falls. A prevention plan should be initiated immediately and documented on
the participant’s interdisciplinary care plan.
1
PARAMETER
A.
B.
C.
D.
E.
SCORE PARTICIPANT STATUS/CONDITION
ALERT – (oriented x3)OR COMATOSE
DISORIENTED x3 at all times
INTERMITTENT CONFUSION
HISTORY OF FALLS
NO FALLS in past 3 months
(past 3 months)
1-2 FALLS in past 3 months
3 or MORE FALLS in past 3 months
AMBULATION/
AMBULATORY/CONTINENT
ELIMINATION
CHAIR BOUND – restraints and assist
STATUS
with elimination
4
AMBULATORY/INCONTINENT
VISION STATUS
0
ADEQUATE (with or without glasses)
2
POOR (with or without glasses)
4
LEGALLY BLIND
GAIT/BALANCE
To assess the participant’s gait/balance have
him/her stand on both feet without holding onto
anything, walk forward, walk through a doorway
and make a turn. Please list ALL that apply.
0
Gait/Balance
1
Balance problem while standing
1
Balance while walking
1
Decreased muscular coordination
1
Change in gait pattern when walking
through doorway
1
Jerking or unstable when making turns
1
Requires use of assistive device (cane,
walker, w/c, etc.)
2
NOT APPLICABLE – Unable to perform
any of above
LEVEL OF
CONSCIOUSNESS
MENTAL STATUS
0
2
4
0
2
4
0
2
2
3
Date
4
F.
SYSTOLIC BLOOD
PRESSURE
G.
MEDICATIONS
H.
PREDISPOSING
DISEASES
TOTAL SCORE
ASSESS
0
NO NOTED DROP between lying &
standing
2
Drop LESS THAN 20 mm Hg between
lying & standing
4
Drop MORE THAN 20 mm HG between
lying & standing
Respond below based on the following types of
meds: Diuretics, Narcotics, Sedatives, Hypnotics,
Psychotropics, Cathartics, Anesthetics,
Antihistamines, Antihypertensives, Antiseizure,
Benzodiazepines
0
NONE of these meds taken currently or
within the last 7 days.
2
TAKES 1-2 of these meds currently
and/or within the last 7 days.
4
TAKES 3-4 of these meds currently
and/or within the last 7 days
1
If participant have had a change in meds
and/or doses in the past 5 days. TAKE
THIS ADDITIONAL POINT
Respond below based on the following conditions:
Hypotension, Vertigo, Parkinson’s Disease,
Seizures, Loss of Limbs, Arthritis, Fractures,
Osteoporosis, CVA
0
NONE PRESENT
2
1-2 PRESENT
4
3 OR MORE PRESENT
Total score of 10 or more HIGH RISK
FOR FALLS
SIGNATURE/TITLE/DATE
ASSESS
1
3
2
4
SIGNATURE/TITLE/DATE