Fall Risk Checklist

Patient: Date: Time: AM/PM

Fall Risk Factor Identified Factor Present? Notes

Falls History
Any falls in past year? Yes No
Worries about falling or feels unsteady
Yes No
when standing or walking?
Medical Conditions
Problems with heart rate and/or rhythm Yes No
Cognitive impairment Yes No
Incontinence Yes No
Depression Yes No
Foot problems Yes No
Other medical conditions (Specify) Yes No
Medications (Prescriptions, OTCs, supplements)
CNS or psychoactive medications Yes No
Medications that can cause sedation or confusion Yes No
Medications that can cause hypotension Yes No
Gait, Strength & Balance
Timed Up and Go (TUG) Test
12 seconds
Yes No

30-Second Chair Stand Test

Yes No
Below average score based on age and gender
4-Stage Balance Test
Yes No
Full tandem stance <10 seconds
Vision
Acuity <20/40 OR no eye exam in >1 year Yes No
Postural Hypotension

A decrease in systolic BP 20 mm Hg or a

diastolic bp of 10 mm Hg or lightheadedness Yes No
or dizziness from lying to standing?
Other Risk Factors (Specify)
Yes No
Yes No

Centers for Disease

Control and Prevention 2015
National Center for Injury
Prevention and Control
CS259944J