Post-Fall Assessment Form
Document key details, observations, and follow-up needs after a fall incident. Please complete all fields as accurately as possible.
Date and time of incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of fall
*
Please Select
Bedroom
Bathroom
Hallway
Kitchen
Living Room
Outdoors
Other
Brief description of the incident
*
Was the fall witnessed?
*
Yes
No
Observed condition immediately after fall
*
Alert and responsive
Disoriented
Complaints of pain
Unable to get up
Other
Visible signs after incident
*
No visible signs
Redness
Bruising
Swelling
Other
Assistance provided after fall
*
Helped to stand
Assisted to chair/bed
Observation only
Other
Environmental factors present
*
Wet floor
Obstacles/tripping hazards
Poor lighting
None
Other
Risk rating for future falls
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Recommended follow-up actions
Rows
Action Needed
Completed
Monitor for changes
1
2
Environmental review
3
4
Arrange further assessment
5
6
Notify responsible party
7
8
Submit Assessment
Should be Empty: