Rehabilitation Center Fall Risk Assessment Form
Patient Information
Name
Patient ID
Date
Assessor
Assessment Criteria
History of Falls (last 6 months)
No
Yes
Uses Mobility Aid
None
Cane
Walker
Wheelchair
Other
Gait/Balance Impairment
Normal
Impaired
Unable
On Medication Affecting Balance
No
Yes
Mental Status
Alert
Confused
Disoriented
Vision Impairment
No
Yes
Urinary/Bowel Control Issues
No
Yes
Assessment Notes
Additional Comments
Assessor Signature
Signature
Date