Fall Risk Screening Form

The Fall Risk Screening Form is designed for assessing and reducing fall risk in older adults, the leading cause of injury-related death in people over 65. Based on the CDC STEADI (Stopping Elderly Accidents, Deaths & Injuries) protocol, this template captures the key risk factors that predict falls: fall history, medication use (especially fall-risk-increasing drugs), mobility and balance assessment, vision concerns, and environmental hazards.

The fall history section documents the number and circumstances of falls in the past year, including injuries sustained, location, and contributing factors. The medication review flags high-risk drug categories: sedatives, antihypertensives, antidepressants, and polypharmacy (4+ medications). A simplified mobility screen captures the patient's self-reported confidence in balance and walking.

Environmental hazard assessment covers common home risk factors: loose rugs, poor lighting, bathroom grab bars, stair railings, and footwear. The fear of falling section is important because fear itself leads to activity restriction, deconditioning, and paradoxically increased fall risk. This template produces a risk score that guides clinical intervention -- from education and exercise referral for low-risk patients to comprehensive geriatric assessment for high-risk patients.