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Fall risk assessment form

Fall risk assessment form

Prevent patient falls with the help of this assessment form. Identify contributing factors, determine risk levels, and create strong prevention strategies.

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Fall risk assessment form

Prevent patient falls with the help of this assessment form. Identify contributing factors, determine risk levels, and create strong prevention strategies.

Use this template with Lumiform

  • Customize this template or build your own
  • Fill out templates via mobile app
  • Get reports and analyse your data
Prices start from ░░░ per month
Book a demo
Learn more
or Download template as PDF

Implement better prevention strategies with our targeted assessment form for identifying fall risks. This tool goes beyond basic screening by evaluating multiple risk dimensions including personal history, mobility aids, and environmental factors to assign accurate risk levels. For example, a healthcare facility might uncover that inadequate lighting contributes significantly to patient fall incidents.

Research shows that more than 50% of older adults who fall receive treatment at a hospital. By documenting specific action plans and notification protocols, this form creates accountability in your prevention program while providing documentation.

Related categories

  • Health and safety management templates
  • Health care templates
  • Risk assessment templates

Created by

Author Name Inioluwa Ademuwagun
Preview of the template
Page 1
General Information
Name
Date
Department
Job Title
Fall Risk Assessment
Have you experienced a fall in the past year?
Do you use any assistive devices (cane, walker, etc.)?
Do you have any conditions that may increase your fall risk (e.g., vision, hearing, or balance issues)?
Are there any environmental hazards in your work area (e.g., slippery floors, clutter, poor lighting)?
Have you received any fall prevention training?
What is your current fall risk level?
Action Plan
Describe any steps you will take to reduce your fall risk:
Who will you notify about your fall risk?

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Related resources

Access a complete set of resources aimed at maximizing safety, quality, and operational excellence, including detailed guides, related templates, and real-world use cases.

Topic guides

Read in-depth guides covering key topics related to this article.

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Frequently asked questions

How can I customize this fall risk assessment form for my specific healthcare facility?

You can adapt this form by adding facility-specific environmental hazards, incorporating your internal risk scoring system, or expanding the action plan section to align with your existing fall prevention protocols. The digital version allows for easy modification while maintaining the core assessment structure that ensures comprehensive risk evaluation.

How do I determine if someone should be classified as “high risk” using this form?

Consider a patient high risk if they’ve had multiple falls in the past year, use multiple assistive devices, have significant sensory or cognitive impairments, or take medications known to increase fall risk. The form’s cumulative responses provide guidance, but clinical judgment remains essential in making the final risk determination.

Who needs to be notified about a patient’s fall risk status?

Notify the direct care team, including nurses, aides, physical therapists, and physicians. For moderate to high-risk patients, also inform family members, transportation staff, and any specialists involved in care. The notification ensures consistent application of fall prevention measures across all interactions with the patient.

Author
Inioluwa Ademuwagun
Inioluwa is a freelance content writer with a passion for words and everything marketing. She has worked closely with B2B SaaS and e-commerce brands creating product-led content. She loves to read fiction and would describe herself as an introverted nerd who desires to travel around the world. She currently doing that with her words till she can with her eyes
This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.
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