Name of Individual____________________________________________________________

 Date: ____________________

When assessing an individual’s risk for falling, consider the following significant factors. An individual’s risk for falling increases with the number of checked items.	
Check if applicable to individual	
Did the individual experience any fall(s) in the last month?			
Is the individual confused (i.e., unable to make purposeful decisions, has disorganized thinking and memory impairment)?		
Is the individual disoriented (i.e., lacks awareness of or is mistaken about time, place, or person)?		
Is the client agitated (i.e., shows fearful affect, makes frequent movements, or is anxious)?		
Are there any alterations in urination (e.g., frequency, urgency, incontinence)?		
Is the individual’s vision impaired (with and without glasses)		
Is the individual’s hearing impaired?		
Is the individual taking more than four prescription drugs?		
Does the individual have a seizure disorder?		
Does the individual have postural hypotension/dizziness?		
Does the individual have weak arm or leg strength?		
Does the individual have unsteady balance?		
Does the individual need verbal or physical assistance when walking or transferring? (i.e. from a bed to standing position)?		
Does the individual require a walking aid?		

Reviewer’s signature_______________________________________

Remember: The more checks an individual has, the more at risk they are for a fall. Based on this information, staff may need to consider a more thorough falls assessment.