Post-Surgery Fall Risk Monitoring Form
Patient Name
Patient ID / MRN
Date
Type of Surgery
Time of Assessment
Fall Risk Factors (Check all that apply)
History of falls
Impaired mobility
Altered mental status
Dizziness/Vertigo
Use of assistive devices
Post-anesthesia effects
Medication effects
Other
Details/Comments
Risk Level
Low
Moderate
High
Interventions Initiated
Nurse/Clinician Name