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Fall Risk Evaluation Form - Free Healthcare Template | ZenBuild | ZenBuild

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Fall Risk Evaluation Form

Fall risk evaluation form for assessing mobility, balance, and environmental hazards in elderly and at-risk patients. Used by hospitals, skilled nursing facilities, and home health providers.

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Fall Risk Evaluation

Complete this evaluation to assess fall risk and identify preventive measures.

Patient Name*

Age*

Have you fallen in the past 6 months?*

No falls1 fall2 or more falls

Risk Factors (select all that apply)

Use of walking aid (cane, walker, wheelchair)Vision impairmentDizziness or vertigoMedications causing drowsinessLower extremity weaknessIncontinence (urgency)Cognitive impairment

Mobility Level*

Can the patient rise from a chair without using arms?*

Yes, easilyYes, with difficultyNo, unable

Environmental Hazards Noted

Prevention Plan / Recommendations

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

Uses0

Views0

healthcarefall-riskgeriatricssafety