Fall Risk Assessment Checklist Form
Complete this checklist to assess fall risk factors and current mobility/safety status. Use this form to systematically evaluate each area for fall risk.
Person Name or Identifier
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name
*
Mobility Status
*
Independent
Needs assistive device
Requires physical assistance
Bedbound
Assistive Device Used
*
None
Cane
Walker
Wheelchair
Other
History of Falls in the Past Year
*
No falls
1 fall
2 or more falls
Unknown
Dizziness or Balance Concerns
*
No issues
Occasional dizziness
Frequent balance loss
Medication-Related Fall Concerns
*
No concerns
Takes medications increasing fall risk
Recent medication changes
Vision Concerns
*
No vision issues
Wears corrective lenses
Impaired vision
Home/Environmental Hazards Present
*
Loose rugs/mats
Poor lighting
Clutter/obstacles
No hazards observed
Overall Fall Risk Rating
*
1
2
3
4
5
Submit Assessment
Should be Empty: