Agency Name / LOGO
Fall Risk Assessment
Patient Name:
I.D.:
Date:
Instructions: On admission, p.r.n., and discharge, assess the patient in the eight clinical condition parameters listed
below (A-H) by assigning the corresponding score which best describes the patient in the appropriate assessment
column. Add the numbers to obtain the total score. If the total score is 10 or greater, the patient should be
considered at High Risk for potential falls, and a referral to the Physical Therapist is to be made.
Parameter
A.
B.
C.
Score
Level of
Consciousness/
Mental Status
History of Falls
(past 3 months)
D.
Ambulation/
Elimination
Status
Vision Status
E.
Gait/Balance
F.
Systolic Blood
Pressure
G.
Medications
0
2
4
0
2
4
0
2
4
0
2
4
0
1
1
1
1
1
1
0
2
4
Gait/balance normal
Balance problem while standing
Balance problem while walking
Decreased muscular coordination
Change in gait pattern when walking through doorway
Jerking or unstable when making turns
Requires use of assistive device (cane, w/c, furniture..)
No noted drop between lying and standing
Drop < 20mmHg between lying and standing
Drop > 20mmHg between lying and standing
Respond below based on the following types of medications: anesthetics,
antihistamines, antihypertensives, antiseizure, bendodiazepines, cathartics,
diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics.
2
4
1
Predisposing
Diseases
Alert – (oriented x 3) or Comatose
Disoriented x 3 at all times
Intermittent confusion
No falls (in past 3 months)
1-2 falls (in past 3 months)
3 or more falls (in past 3 months)
Ambulatory/continent
Chairbound (requires restraints & assist w/elimination)
Ambulatory/incontinent
Adequate (with or without glasses)
Poor (with or without glasses)
Legally blind
To assess the gait/balance, have patient stand on both feet without holding onto
anything; walk straight forward; walk through a doorway; and make a turn.
0
H.
Patient Status/Condition
None of these medications taken currently or w/in last
7 days
Takes 1-2 of these medications currently and/or w/in
last 7 days
Takes 3-4 of these medications currently and/or w/in
last 7 days.
If patient has had a change in medication and/or change
in dosage in past 5 days = score 1 additional point
Respond below based on the following predisposing conditions: hypotension,
vertigo, CVA, Parkinson’s disease, loss of limb(s), seizures, arthritis,
osteoporosis, fractures
0
2
4
None present
1-2 present
3 or more present
STAFF COMPLETING FORM
TOTAL SCORE
(Total score of 10 represents High Risk)
Admit
PRN
Disch