A fall risk assessment records why an older adult has fallen, or may fall, and what will change: past falls, strength and balance, blood pressure, medications, vision, feet, bones, and home. Copy the free template, see an annual visit and an after-the-emergency-visit example, and check what goes in each part.
Blank fall risk assessment template
FreeFALL RISK ASSESSMENT Patient: [Name, age] Date: [Date] Setting: [Clinic, home visit, or follow-up after an emergency visit] Reason: [Annual screen, positive screen, recent fall, or referral] Others present: [Name and relationship, or none] Clinician: [Name, credentials] SCREENING Key questions: [Fallen in the past year, unsteady when standing or walking, worried about falling: yes or no to each] Self-check: [Stay Independent checklist score, or not used] Result: [Positive or negative, and the approach followed, such as CDC STEADI or the World Falls Guidelines] FALLS IN THE PAST YEAR Number of falls: [How many, and when] How each happened: [Where, time of day, what the person was doing; trip, slip, legs gave way, or dizziness] Symptoms before: [Lightheadedness, palpitations, chest pain, loss of consciousness, or none] Injuries: [Injuries, emergency visits, imaging and results] Getting up: [Got up alone, or time on the floor and how help came] Fear of falling: [Worry, activities given up, Short FES-I score if used] GAIT, STRENGTH AND BALANCE Timed Up and Go: [Seconds, walking aid, what you saw] 30-second chair stand: [Number of full stands, or 0 if arms were needed] 4-stage balance test: [Each stage held for 10 seconds, and where the person stopped] Gait: [Pace, step length, turning, reaching for furniture, walking aid at home and outside] ORTHOSTATIC BLOOD PRESSURE Lying: [BP and pulse after 5 minutes lying down] Standing: [BP and pulse at 1 and 3 minutes, and any symptoms] Result: [Drop in systolic and diastolic, and whether it is orthostatic hypotension] MEDICATION REVIEW Medications: [Every prescription, over-the-counter and herbal product, with dose and timing] Number of medications: [Total] Fall-risk-increasing drugs: [Sedatives, sleep medications, antidepressants, antipsychotics, opioids, blood pressure medications, diuretics, anticholinergics, diabetes medications that can cause lows] Decision for each: [Stop, taper, lower the dose, change the timing, or continue, and why] OTHER RISK FACTORS Vision: [Visual acuity, glasses, last eye exam, cataract] Feet and footwear: [Pain, deformity, sensation, shoes worn at home and outside] Continence: [Urgency, leaks, night trips to the bathroom] Cognition and mood: [Screen used and score, low mood] Bone health: [Fractures as an adult, bone density result, fracture risk score] Other conditions: [Heart, neurological, joint, diabetes, alcohol use] Home: [Who lives there, stairs and rails, rugs, lighting, bathroom, personal alarm] RISK LEVEL Level: [Low, intermediate, or high] Reasons: [The findings that set the level] PLAN Exercise: [Strength and balance program or physical therapy referral, and how often] Medications: [Changes, taper schedule, and who monitors] Home safety: [Checklist given, changes agreed, or occupational therapy home assessment] Vision, feet, and continence: [Referrals and changes] Bone health: [Bone density test, fracture risk, treatment, vitamin D only where indicated] Getting help: [Personal alarm, phone within reach, practice getting up from the floor] Education: [What was discussed, and with whom] Follow-up: [Date, and what will be rechecked] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Primary care, annual visit, in person, with her husband
79-year-old woman. Yes to all three key questions: one fall since her last visit, unsteady on stairs and uneven ground, and worried about falling. Screen positive, following the CDC STEADI approach; full assessment done today.
One fall in July at about 3 a.m., walking to the bathroom in the dark. Her foot caught the curled edge of the bath mat and she sat down hard. No dizziness beforehand, no palpitations, no blackout. No injury; no care sought. Got up on her own within a few minutes by holding the edge of the tub. Had taken her lorazepam at bedtime. Since then she has stopped her weekly walking group and holds the rail on every step. Short FES-I 15: high concern about falling.
Timed Up and Go 16 seconds, no walking aid: slow to rise, short steps, a wide turn in 4 steps. 30-second chair stand: 7 stands without arms; below average for women aged 75 to 79 is fewer than 10. 4-stage balance test: feet together and semi-tandem held 10 seconds each; tandem 4 seconds. No shuffling; walks steadily on the flat.
After 5 minutes lying: 134/76, pulse 70. Standing at 1 minute: 128/74, pulse 78. At 3 minutes: 130/74, pulse 76. No symptoms. No orthostatic hypotension.
6 medications, from the bottles she brought: lorazepam 1 mg at bedtime for 8 years, started when her husband was in hospital; an over-the-counter night-time pain reliever with diphenhydramine, 2 or 3 nights a week for her knee; amlodipine 5 mg; ramipril 10 mg; atorvastatin 20 mg; omeprazole 20 mg since a stomach upset 3 years ago. Fall-risk-increasing drugs: lorazepam and diphenhydramine, both sedating and sometimes taken on the same night. Amlodipine and ramipril: BP at target with no orthostatic drop, so continued. Omeprazole: no ongoing reason; review at the next visit.
Vision: distance acuity 20/40 in each eye without glasses; reading glasses only; last eye exam 3 years ago. Feet: bunions, sensation normal; wears backless slippers at home. Continence: up twice a night to pass urine, no leaks. Cognition and mood: Mini-Cog 5 of 5; PHQ-2 1. Bone health: no fractures as an adult; 3 cm height loss; bone density 5 years ago, lowest T-score −2.1 at the femoral neck; milk and yogurt daily, in the garden most days. Other: knee osteoarthritis; 1 glass of wine on Saturdays. Home: two-storey house with her husband, bedroom upstairs, rails on both sides of the stairs, no night light between bedroom and bathroom, loose bath mat, no grab bars.
Intermediate. One fall without injury, got up alone, no blackout, not frail: no high risk features. TUG 16 seconds, a below-average chair stand, and tandem stance under 10 seconds show a gait and balance problem. Sedating medications and the dark route to the bathroom add to it.
Exercise: physical therapy referral for a progressive strength and balance program, then the Otago home exercises 3 times a week for at least 12 weeks; she aims to rejoin her walking group. Medications: lorazepam reduced by about a quarter every 2 weeks, with smaller steps near the end; written schedule and sleep diary given; self-guided CBT for insomnia started. Diphenhydramine product stopped; acetaminophen for her knee instead. Home safety: plug-in night lights from bedroom to bathroom, bath mat removed, grab bar by the toilet; home safety checklist given, and her husband will do these this week. Vision and feet: eye exam with an optometrist; closed-heel slippers with non-slip soles. Bone health: repeat bone density test; FRAX with the result, and treatment discussed then. No vitamin D started: good intake and time outdoors, and it wouldn’t prevent falls. Follow-up: 4 weeks for sleep and the taper; repeat TUG, chair stand, and balance test at 3 months.
Primary care, 5 days after an emergency department visit, with his daughter
84-year-old man seen after a fall that led to an emergency visit. Two falls in the past year, lightheaded when he gets up, and now afraid to walk at night. Screen positive; full assessment done today.
Fall 1, August: tripped on the hall runner in daylight; no injury; got up alone. Fall 2, November 3, at about 2 a.m.: got out of bed to pass urine, felt lightheaded after a few steps, and his legs gave way; landed on his left hip. No loss of consciousness by his account, no chest pain or palpitations. Could not get up; lay on the floor for about 40 minutes until he reached his phone and called his daughter. Emergency department: X-ray of the left hip and pelvis, no fracture; ECG sinus rhythm, no acute changes; sodium 132. Large bruise over the left hip, healing. Fear of falling: has cut back on drinks in the evening so he won’t have to get up.
Timed Up and Go 22 seconds with his cane: pushed up with both arms, short steps, reached for the desk on the turn. 30-second chair stand: could not stand without using his arms, scored 0. 4-stage balance test: feet together 10 seconds; semi-tandem 6 seconds, then stopped. Left hip pain 2 out of 10 on walking.
After 5 minutes lying: 146/80, pulse 72. Standing at 1 minute: 118/70, pulse 90, lightheaded, “the same as that night.” At 3 minutes: 116/68, pulse 92. Drop of 30 mmHg systolic: orthostatic hypotension, with symptoms.
6 medications, from the pharmacy list his daughter brought: amlodipine 10 mg, hydrochlorothiazide 25 mg, tamsulosin 0.4 mg, metformin 500 mg twice a day, atorvastatin 20 mg, and acetaminophen as needed. Fall-risk-increasing drugs: amlodipine, hydrochlorothiazide, and tamsulosin all lower BP on standing; the diuretic also adds night-time urination and low sodium. Metformin alone: no lows. Missed doses since the spring, by his daughter’s count. Decision: stop hydrochlorothiazide; continue amlodipine and tamsulosin for now, one change at a time.
Vision: cataract in the right eye; acuity with glasses 20/60 right, 20/30 left. Feet: thick toenails; reduced monofilament sensation in both feet; wears loose backless slippers. Continence: up 3 times a night with urgency. Cognition and mood: Mini-Cog 2 of 5, recalled 2 words, clock drawing abnormal; PHQ-2 0. Bone health: no fractures; no bone density test on record; little dairy, rarely outdoors. Other conditions: type 2 diabetes, last A1C 7.1%; hypertension; enlarged prostate. No alcohol. Home: lives alone in a bungalow since his wife died; runner rug in the hall; dim hallway with no night lights; no grab bars by the toilet or tub; no personal alarm.
High. Two falls in a year, one with an injury and an emergency visit, and 40 minutes on the floor. Changeable factors: symptomatic orthostatic hypotension on three BP-lowering drugs, low sodium, TUG 22 seconds, weak legs, cataract, slippers, and home hazards.
Medications: hydrochlorothiazide stopped. Pharmacy blister packs, with his daughter checking weekly. Lying and standing BP, sodium, and creatinine in 2 weeks; lower amlodipine to 5 mg next if the drop persists. Standing up: sit on the edge of the bed for a minute first; drink normally through the day; urinal by the bed at night. Home safety: occupational therapy home safety assessment booked for next week; his daughter removed the hall runner and put in night lights today; grab bars and a raised toilet seat as the therapist advises. Exercise: home physical therapy for strength and balance, practice getting up from the floor, and whether a walker suits him better indoors. Getting help: personal alarm pendant worn day and night. Vision and feet: referral for cataract surgery assessment, right eye; foot care referral; closed shoes with a firm heel. Bone health: bone density test, FRAX with the result; daily vitamin D started for low intake and little time outdoors. Cognition: full cognitive assessment at follow-up. Follow-up: 2 weeks, with his daughter; repeat TUG once the hip has settled.
The quick check that decides who needs the full assessment. Most clinicians ask three questions each year from age 65, as in the CDC’s STEADI approach.
Avoid: Stopping at “positive screen.” A yes to any question means the rest of the assessment, today or at a booked visit.
Each fall’s story: what the person was doing, what they felt before, what they hit, and how they got up. The cause is usually in these details.
Avoid: Writing “mechanical fall” and moving on. Ask what happened just before. Dizziness on standing or a blackout points to a medical cause.
Timed tests that show how steady the person is, with numbers you can repeat at follow-up to see whether the plan is working.
Avoid: “Gait unsteady” with no test. A time or a count shows how unsteady, and whether the person improves.
Blood pressure lying and standing, to find a drop that makes the person lightheaded when they get up.
Avoid: Checking only a seated BP. Most orthostatic drops are missed unless you measure lying and then standing.
Every medicine the person takes, with a decision on each one that can raise the risk of falling.
Avoid: Listing the risky drugs with no plan. Name the change, the taper schedule, and when you’ll check on it.
The rest of the multifactorial assessment: what the person sees, stands on, gets up at night for, and lives in, and how strong their bones are if they do fall.
Avoid: Leaving out bone health. A fall becomes a hip fracture when the bones are weak, so fracture risk is part of the same assessment.
Your judgment of how likely a serious fall is, and the findings behind it. The World Falls Guidelines sort people into low, intermediate, and high risk.
Avoid: A level with no reasons. The next clinician needs the findings that put the person in that group.
What will be done about each risk you found, matched to the level, with someone named for each step.
Avoid: A leaflet as the whole plan. Advice to “be careful” changes nothing. Exercise, medication changes, and home changes do.
Yes to a key question is where the assessment starts. Test gait and balance, check lying and standing BP, and review the medications, or book a visit to do it.
A trip can still have a cause you can change: lightheadedness on standing, a sleeping pill, poor vision, or weak legs. Ask what happened just before, and why the person couldn’t recover.
“Mobility reduced” can’t be compared next time. Record the Timed Up and Go in seconds, the chair stands, and the last balance stage held.
Orthostatic hypotension is found by measuring after 5 minutes lying, then at 1 and 3 minutes standing. Note symptoms too.
Vitamin D supplements don’t prevent falls in people whose levels aren’t low. Give it for low intake, deficiency, or bone treatment, and put exercise first.
Lying on the floor for an hour or more brings dehydration, pressure injury, and fear. Ask whether the person could get up, and plan an alarm and floor-rise practice.
Vero Scribe drafts the fall risk assessment in your template from the visit, with the patient’s consent, or from your dictation, including the test results you read out. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Falls in the past year and how they happened, fear of falling, timed gait and balance tests, lying and standing blood pressure, a medication review, vision, feet and footwear, continence, cognition, bone health, and home hazards. End with a risk level and a plan for each factor you found.
STEADI, short for Stopping Elderly Accidents, Deaths and Injuries, is the CDC’s toolkit for fall prevention in primary care. It has three steps: screen adults 65 and older each year, assess the risk factors of those who screen positive, and intervene. Screening uses three key questions or the 12-item Stay Independent self-check, where 4 or more points flags risk. The assessment uses the Timed Up and Go, the 30-second chair stand, and the 4-stage balance test. This template follows the same steps, in your own record.
Screen adults 65 and older at least once a year. Do the full assessment when the screen is positive, and always after a fall with injury, two or more falls in a year, a fall where the person couldn’t get up, or a fall with a possible blackout. The World Falls Guidelines call these high risk.
STEADI treats 12 seconds or more as a sign of fall risk. The World Falls Guidelines use more than 15 seconds, or a walking speed under 0.8 meters a second, to find people who need strength and balance training. Record the time, any walking aid, and what you saw, such as a slow start or a broken turn.
Have the person lie down for 5 minutes, then take BP and pulse. Ask them to stand, and measure again at 1 minute and 3 minutes. A drop of 20 mmHg systolic or 10 mmHg diastolic is orthostatic hypotension. Write down any lightheadedness, even when the numbers don’t meet the threshold.
The Morse Fall Scale is a quick nursing score for patients in hospital, used to set bedside precautions. A fall risk assessment for someone living at home looks for causes you can change, such as weak legs, sedating drugs, a drop in blood pressure, poor vision, or a dark hallway, and ends with a plan to change them.
Yes. Copy it, or download it as a Word or text file. No account needed.
Capacity for one decision at one time: the information given, the four abilities in the patient’s words, the finding, and who decides next.
The clinician’s assessment after a positive screen: ideation, intent, means, the formulation, and the plan.
The full pre-op assessment before noncardiac surgery: history, capacity, RCRI, airway, medication plan, and a clear recommendation.
System-by-system exam with normal findings written out, space for abnormal findings, and sensitive exams when indicated.
After a job offer: the job’s demands, relevant history, immunizations, vision and hearing, a job-focused exam and tests, and a fit outcome without the diagnosis.
Complex visits, care plans, and caregiver guidance, drafted for your review.
How Vero drafts primary care notes from the visit for you to review.
Evaluations and visits that tie test results to function.
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