Fall Risk Assessment for Mobility-Impaired Patients

Patient Information

Patient Name Date of Assessment Assessor Name Patient ID

Risk Factor Assessment

Risk Factor	Present?	Details / Notes
History of Falls	Yes No
Impaired Mobility	Yes No
Use of Assistive Devices	Yes No
Medication Effects (e.g., dizziness)	Yes No
Sensory Deficits (Vision/Hearing)	Yes No
Cognitive Impairment	Yes No
Incontinence/Urinary Urgency	Yes No
Environmental Hazards	Yes No

Mobility Assessment

Level of Assistance Required Independent Supervision Minimal Assistance Moderate Assistance Maximum Assistance Assistive Devices Used Gait and Balance Observations

Recommendations / Interventions

Additional Notes