Geriatric Mobility Risk Assessment
Patient Information
Name
Age
Patient ID
Mobility Level
Select mobility level
Independent
Assisted
Dependent
Fall History
Number of falls in the past year
Assistive Devices
Does the patient use any assistive devices?
None
Cane
Walker
Wheelchair
Other
Physical Assessment
Gait Stability
Stable
Unsteady
Requires Assistance
Balance
Good
Fair
Poor
Muscle Strength
Normal
Mild Weakness
Severe Weakness
Cognitive Assessment
Cognitive Status
Alert & Oriented
Disoriented
Memory Issues
Notes
Additional Comments