Fall Risk Assessment Tool
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3Fall Risk Assessment Tool
Resident: _______________________________________
Home: _____________________
Category
Value
Resident status
Score
History of falls in
No falls
0
1-2 falls
1
past 3 months
2
3 or more falls
(Choose one)
Ambulation
0
Independent
Non-ambulatory
1
(May choose more than
Unable to get up from sitting position
2
one)
without assistance
Full assist required
3
Gait/Balance
0
Normal
Unsteady at times
1
(Choose one)
Requires assistive device
2
Independently propels w/c
3
Sleep Patterns
0
Normal
1
Sleeps less than 6 hours a night
(Choose one)
Sleeps less than 4 hours a night
2
Vision
0
Adequate with or without glasses
Poor
2
(Choose one)
Blind
4
Oriented times three
Mental Status
0
2
Intermittent confusion
(Choose one)
4
Disoriented times three
Takes 1-2 medications daily
Medications
2
3
Takes 2-9 medications daily
(May choose more than
4
Take 9+ medications daily
one)
3
Takes psychotropic medications
Adaptive
No adaptive equipment needed
0
Orthotic Shoes
1
Equipment
AFO’s
(May choose more than
1
one)
Cane
2
Walker
2
Wheelchair
2
Arthritis/Osteoporosis
Chronic Medical
1
1
Cerebral Palsy
Conditions
1
Diabetes
(May choose more than
1
Dementia
one)
Peripheral Neuropathy
1
Cardiac Condition
1
Hemiplegia
2
2
Extremity contractures/fractures
2
H/O Stroke/TIA
2
Seizure activity within the past 12 months
Total Score: ___________________
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