Home Fall Risk Assessment Form
Use this form to assess fall risk factors in a home environment and identify safety concerns that may need follow-up.
Assessment Overview
Respondent Name
*
First Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Environment Type
*
Please Select
House
Apartment
Assisted Living
Other
Address or Location Label
Mobility and Personal Fall History
Mobility Aid Used
*
None
Cane
Walker
Wheelchair
Other
Fallen in the Past 12 Months
*
Yes
No
Number of Falls in the Past 12 Months
Current Symptoms or Concerns
Dizziness
Balance problems
Weakness
None of these
Other
Home Environment Risk Checklist
Home hazard checklist by room/area
*
Rows
Yes
No
Not applicable
Stairs/handrails
1
2
3
Bathroom/grab bars
4
5
6
Hallway lighting
7
8
9
Bedroom floor/clutter
10
11
12
Kitchen walkways
13
14
15
Entryway/thresholds
16
17
18
Loose rugs
19
20
21
Uneven floors
22
23
24
Blocked walkways
25
26
27
Hazard severity by area
Rows
Low
Moderate
High
Stairs/handrails
28
29
30
Bathroom/grab bars
31
32
33
Hallway lighting
34
35
36
Bedroom floor/clutter
37
38
39
Kitchen walkways
40
41
42
Entryway/thresholds
43
44
45
Loose rugs
46
47
48
Uneven floors
49
50
51
Blocked walkways
52
53
54
Areas with identified hazards
Stairs
Bathroom
Hallway
Bedroom
Kitchen
Entryway
Other
Overall home hazard rating
*
1
2
3
4
5
Overall Risk and Follow-Up
Overall fall risk rating
*
Low risk
1
2
3
4
5
6
7
8
9
High risk
10
1 is Low risk, 10 is High risk
Recommended priority level
*
Low
Moderate
High
Recommendations or follow-up actions
Submit
Should be Empty: