Fall Risk Screening Form
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Fall Risk Screening Form
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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.
What's included
- Fall history documentation with circumstances
- Medication review for fall-risk drugs
- Balance and mobility self-assessment
- Home environmental hazard checklist
- Fear of falling evaluation
- Risk score and intervention recommendations
- Structured medication list with dosage and frequency tracking
Who uses this template
- Geriatric and senior care practices
- Primary care annual wellness visits for 65+
- Home health and visiting nurse services
- Skilled nursing and rehabilitation facilities
All form fields
10 fields across 2 pages. Customize any field after signing up.
How to use the Fall Risk Screening Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Fall Risk Screening Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Fall Risk Screening Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 10 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Fall Risk Screening Form HIPAA compliant?
Yes. All Formisoft templates, including the Fall Risk Screening Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 10 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Fall Risk Screening Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
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