Assisted Living Facility Fall Risk Screening
Resident Name
Date of Birth
Date of Assessment
Assessor Name
Fall Risk Factors
History of falls in the past 6 months
Uses mobility aid
Gait/balance impairment
Taking medications affecting balance
Cognitive impairment
Visual impairment
Incontinence or urgency
Environmental hazards present
Observation & Assessment
Observations
Assessment Notes
Risk Level
Low
Moderate
High
Fall Prevention Recommendations