Fall Risk Assessment, Functional Ability, Safety Screen

Name:

Date:

Date of Birth:

Have you had any falls in the past year?

Yes No

If yes, have you had: One fall in the past year but WITHOUT injury?

Yes No N/A

Any fall in the past year WITH an injury?

Yes No N/A

Two or more falls in the past year?

Yes No N/A

Do you need to use any ambulatory aids, such as a cane, walker or crutches?

Yes No

Do you need to clutch onto furniture for support when you walk?

Yes No

Do you use a wheelchair or require bedrest due to difficulty walking?

Yes No

Does your home have adequate lighting, as well as handrails/guardrails where needed?

Yes No

Does your home have hallway rugs or floor coverings that have frayed or rolled edges?

Yes No

Is it difficult for you to get on/off the toilet?

Yes No

Do you need assistance with eating, bathing, dressing, personal hygiene, housekeeping, or paying bills?

Yes No

Do you experience urinary incontinence?

Yes No

Do you experience any difficulties with hearing?

Yes No