ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
Date of Visits:
2
RISK FOR FALL:
3
History of Falling: within past 3 months o Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso No
4
Ambulatory Aids:
5
Wheelchairo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso No
6
Crutches/Cane/Walkero Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso No
7
Uses furniture for support
o Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso No
8
Gait/Transferring:
9
Bedrest/immobileo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso No
10
Weako Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso No
11
Impairedo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso No
12
Mental Status:
13
Forgets Limitationso Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso Noo Yeso No
14
Interventions To be Initiated if any of the above criteria is YES = Risk for Falling
15
1.  Escort while ambulating
16
2.   Assist Patient
17
3.   Ensure fasten the seat belt while in wheelchair / Stretcher, etc.
18
4. Educate patient and family on fall precautions / preventions.
19
Nurse's Initial and No.
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100