Post-Stroke Fall Risk Assessment Worksheet
Patient Information
Name:
Date of Birth:
Assessment Date:
Assessor:
Risk Factors
History of falls post-stroke
Mobility impairment
Vision impairment
Cognitive impairment
Incontinence
Sedative use
Dizziness/balance issues
Muscle weakness
Functional Assessments
Test
Score/Notes
Berg Balance Scale
Timed Up and Go (TUG)
Gait Assessment
Other
Environmental Assessment
Hazards/noted risks in patient environment:
Recommendations/Interventions
Re-assessment Date