Fall Risk Assessment Tool (Page 2 of 3) in pdf

Fall Risk Assessment Tool

Results of Fall Risk Assessment

Total score less than 8 (Minimal fall risk)

A score of less than 8 is identified as a minimal fall risk. This person is at low risk for chronic

falls and no extra precautionary measures are needed.

Total score of 9-12 (Moderate fall risk)

A person with a score of 9-12 points is identified as a moderate fall risk and should be evaluated

by Physical Therapy or other medical professional to assess need for fall precautions.

Score of 13+ (Severe fall risk)

A person with a score of greater than 13 is identified as a severe fall risk and should be evaluated

by Physical Therapy immediately for necessary precautions. If precautions are already in place

they should be addressed in the IP.

Reason for completing assessment:

Admission to the facility

Annual IP

Medication change with side effect of change in mental status (To be completed within

30 days of start of new medication) Medication Change: ________________________

Hospitalization greater than 3 days

New diagnosis that could increase risk of falls

Change in adaptive equipment needs

Vision changes

Fracture

Other

Results of assessment:

______________________________________________________________________________

Recommendations:

______________________________________________________________________________

Safety measures already in place:

______________________________________________________________________________

Person completing assessment: __________________________________________________

Date:_______________________________

Fall Risk Assessment Tool Page 2