Fall Risk Care Plan Evaluation Form
Assess fall risk factors and document a care plan for individuals at risk of falls.
Patient Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor's Name and Title
*
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fall Risk Factors Assessment
*
Rows
Yes
No
Not Assessed
History of falls in the past 6 months
1
2
3
Impaired mobility or gait
4
5
6
Use of assistive devices (walker, cane, etc.)
7
8
9
Impaired vision
10
11
12
Medication affecting balance
13
14
15
Cognitive impairment or confusion
16
17
18
Environmental Risk Assessment
*
Rows
Safe
At Risk
Not Assessed
Clutter-free walkways
19
20
21
Adequate lighting
22
23
24
Handrails in place
25
26
27
Non-slip flooring
28
29
30
Bathroom safety equipment
31
32
33
Overall Fall Risk Level
*
Low
Moderate
High
Recommended Interventions (select all that apply)
*
Physical therapy referral
Medication review
Environmental modifications
Vision assessment
Assistive device training
Other
Care Plan Details (describe specific actions, referrals, or follow-up)
*
Follow-up Evaluation Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Assessor
*
Submit Evaluation
Submit Evaluation
Should be Empty: