Elderly Outpatient Fall Risk Evaluation Form
Patient Information
Name
Date of Birth
Medical Record Number
Assessment
History of Falls
Yes
No
Assistive Device Used
None
Cane
Walker
Wheelchair
Other
Number of Medications
Sensory Impairments
Vision
Hearing
None
Cognitive Impairment
Yes
No
Gait / Balance Issues
Yes
No
Mobility Assessment Comments
Environmental Factors
Poor Lighting
Uneven Floors
Obstacles/Clutter
Lack of Handrails
None
Clinical Judgment / Additional Notes