Home Health Care Fall Risk Assessment Form
Patient Information
Patient Name
Date of Birth
Medical Record Number
Assessment Date
Fall Risk Factors
History of falls (past 3 months)
Yes
No
Mobility Issues (requires assistance, unsteady gait, assistive devices, etc.)
Yes
No
Dizziness or Balance Issues
Yes
No
Vision Impairment
Yes
No
Medications That Increase Fall Risk (e.g., sedatives, antihypertensives)
Yes
No
Cognitive Impairment
Yes
No
Continence Issues (incontinence, urgency)
Yes
No
Environmental Assessment
Potential hazards in the home (loose rugs, clutter, poor lighting, etc.):
Additional Notes / Recommendations
Assessor Name
Signature
Date