Visual Impairment Fall Risk Screening Form
Patient Information
Full Name
Date of Birth
Patient ID
Visual Impairment Assessment
Has the patient been diagnosed with a visual impairment?
Yes
No
Type of Visual Impairment
Visual Acuity (if known)
Fall Risk Factors
Has the patient experienced any of the following? (Check all that apply)
Previous fall(s)
Balance difficulty
Uses walking aids
Medications affecting balance
Home hazards
Number of falls in the past 12 months
Additional Notes
Observations / Recommendations