FALL 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]