Dementia Care Fall Hazard Evaluation
Resident Name:
Date:
Evaluator Name:
Personal Risk Factors
Risk Factor
Present
Notes
Cognitive impairment
Impaired mobility/gait
Visual impairment
Medications (sedatives, etc.)
Environmental Risk Factors
Area
Hazard Identified
Action Needed
Bedroom
Bathroom
Hallways
Living Areas
Interventions/Recommendations
Follow-Up
Re-evaluation Date:
Comments: