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FALL RISK ASSESSMENT FORM
Resident Name-
Check off reason for assessment
Initial Assessment
Re-Assessment after fall
Re-Assessment (periodic)
Change in Status
Circle reference
Total reference
Categories
number(s) in
Descriptions
numbers by
each category
category
NO FALLS in past 3 months
Recent Fall History
1 - 2 FALLS in past 3 months
3 OR MORE FALLS in past 3 months
AMBULATORY/CONTINENT
Ambulation / Continence
CHAIR BOUND - Requires assist with elimination
AMBULATORY/INCONTINENT
ALERT (oriented X 3) OR COMATOSE (no voluntary or

involuntary movement)
Mental Status
DISORIENTED X 3 at all times
INTERMITTENT CONFUSION / forgets limitations
ADEQUATE (with or without glasses)
POOR (with or without glasses)
LEGALLY BLIND
To assess, have resident stand on both feet without holding onto anything; walk straight
forward; walk through a doorway; and make a turn.

Gait/Balance normal
Balance problem while standing
Balance problem while walking
Decreased muscular coordination
Change in gait pattern when walking through doorway
Unstable when making turns
Requires use of assistive devices (i.e., cane, w/c, walker,

furniture)
Inappropriate use of assistive device / footwear
NO NOTED DROP between lying and standing
Drop LESS THAN 20 mm Hg between lying and standing in

Blood Pressure (Systolic)
3 minutes
Drop MORE THAN 20 mm Hg between lying and standing

in 3 minutes
Diuretics (somnolence, volume depletion, electrolyte disturbance, urgency to rush to
bathroom), Psychoactives: Benzodiazepines (i.e. Ativan, Halcion), Phenothiazines,
Antidepressants, and antipsychotics (i.e., Mellaril and Haldol), Narcotics, Anticonvulsant
stabilizers, Cardiovascular medications, Corticosteroids (can adversely effect muscle
function), or any medication that adversely affects muscle function, coordination, and physical
stability.

NONE of these medications taken currently or within last 7
Medications
days
TAKES 1 - 2 of these medications currently and/or within

last 7 days
TAKES 3 - 4 of these medications currently and/or within

last 7 days
If resident has had a change in medications and/or

change in dosage in the past 5 days = score 1 additional
point

Gastrointestinal: Bleeding, Diarrhea, Defecation Syncope, Postprandial Syncope,
Genitourinary: Micturition syncope, Incontinence, Nocturia (80% of the elderly experience
nocturia and going to the bathroom at night is a major risk factor), Cardiovascular: Myocardial
infarction, Arrhythmia, Orthostatic Hypotension, Musculoskeletal disorders: Arthritis,

Predisposing Conditions
Inflammatory Joint Disease, Osteoarthritis Proximal Myopathy, Deconditioning, Neurologic:
Parkinsonian, Dementia, Stroke, Transient Ischemic Attack, Delirium, Myelopathy,

Vertebrobasilar Insufficiency, Carotic Sinus Supersensitivity, Cerebellar Disorder, Peripheral
Diseases
Neuropathy, Diabetes, B12 Deficiency, Multiple Myeloma, Vasculitis, Chronic dehydration
NONE PRESENT
1 - 2 PRESENT
3 OR MORE PRESENT
A TOTAL SCORE OF 10 OR MORE INDICATES A
TOTAL SCORE--->
RESIDENT "AT RISK" FOR FALLS.
This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-NY-AIM7.2-11-24

Source: http://qio.ipro.org/wp-content/uploads/2012/12/fall_risk_assessment.pdf

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