Clinical Fall Risk Assessment Questionnaire
Complete this questionnaire to help clinical staff assess fall risk and identify safety concerns.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Sex/Gender
*
Female
Male
Non-binary
Prefer not to say
Prefer to self-describe
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name and Role
*
Mobility and Fall History
Number of Falls in the Past 12 Months
*
Any Falls Caused Injury?
*
Yes
No
Use of Walking Aid or Assistive Device
Please Select
None
Cane
Walker
Wheelchair
Other
Difficulty Walking or Transferring
*
No difficulty
1
2
3
4
5
6
7
8
9
Extreme difficulty
10
1 is No difficulty, 10 is Extreme difficulty
Dizziness or Lightheadedness
Never
Rarely
Sometimes
Often
Always
Balance Problems
No problems
1
2
3
4
5
6
7
8
9
Severe problems
10
1 is No problems, 10 is Severe problems
Medical and Functional Risk Factors
Medications that may increase fall risk
Sedatives or sleep aids
Blood pressure medications
Diuretics
Pain medications
Antidepressants
Antihistamines
Muscle relaxants
Other
Vision problems
None
Mild difficulty
Moderate difficulty
Severe difficulty
Other
Hearing problems
None
Mild difficulty
Moderate difficulty
Severe difficulty
Other
Urinary urgency or nighttime toileting
Never
Occasionally
Frequently
Almost always
Other
History of fainting or seizures
No
Yes, fainting
Yes, seizures
Yes, both
Other
Lower-extremity weakness
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Mobility status for activities of daily living
Rows
Independent
Some assistance
Unable
Walking
1
2
3
Standing
4
5
6
Rising from chair
7
8
9
Stair use
10
11
12
Environment and Safety
Home or care environment type
*
Private home
Assisted living
Long-term care facility
Rehabilitation facility
Other
Recent hazards at home
*
Loose rugs
Poor lighting
Clutter or obstacles
Slippery floors
Stairs without rails
Uneven surfaces
Other
Use of handrails or grab bars
*
Yes, consistently
Yes, sometimes
No
Not applicable
Footwear usually worn
*
Supportive shoes
Slippers
Barefoot
Socks only
Wheelchair or non-ambulatory
Other
Received fall-prevention education
*
Yes
No
Not sure
Clinical Summary and Acknowledgment
Clinician Risk Level
*
Low
Moderate
High
Clinician Risk Summary / Comments
Submit Assessment
Should be Empty: