Hospital Inpatient Fall Risk Scoring Sheet

Patient Information

Patient Name:
Patient ID:
Date:
Assessed By:

Fall Risk Factors

Risk Factor	Criteria	Score
History of falls
Medication (sedatives, antihypertensives, etc.)
Gait/Balance impairment
Confusion/Disorientation
Visual impairment
Toileting needs/Urinary frequency
Mobility aids (walker, cane, etc.)
Other (specify):

Total Score

Risk Level

Score Range	Risk Level

Interventions/Comments