Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Fall Risk Screening Form
Full Name *
Fall History (Past 12 Months)
Fall Circumstances & Injuries
Current Medications (Count)
High-Risk Medications
| Medication | Dose | How often |
|---|---|---|
Balance & Mobility Confidence
Vision Concerns
Home Environmental Hazards
Fear of Falling
Assessment Date
____ / ____ / ________
Fall Risk Screening Form template from formisoft.com. formisoft.com/intake-templates/fall-risk-screening