Assessment - National Fall Prevention Center

6
Gender

Woman

Man

Other

Prefer not to say

7
Approximately how many falls have occurred in the last year.

If there was a fall, what were the general factors that caused the fall(s)?

7A
What is your main ojbective, goal, or reason for completing this evaluaton form?

To keep this assessment as simple as possible, the wording on the form is designed for the individual to take the survey, and all questions are in the first person. So, while you may be filling out the form for someone else, please note that the entire assessment will remain in the first person.

8A
Describes hand and grip:

Extremely weak- cannot open jars

Weak – struggle opening most jars

Average- open jars of goods and comfortably hold grab bar for stability

Strong and Flexible- able to do most or all common task related to hands.

8B
Describes arm strength & flexibility:

Limited flexibility, difficulty putting on socks and shoes

Weak struggle to lift or move objects

Strong and Flexible, carry groceries and put away with little to no difficulty

8C
Describe Leg Strength

Weak - struggle getting out of chairs or using stairs

Average- slight difficulty getting out of chair

Strong- transition from floor to standing with ease

8D
Shortness of breath occurs:

With minimum physical exertion - walking less than 20 feet

With some physical exertion- walking 20-100 feet

With extended duration of walking or intense physical exertion

Never

8E
When is it a challenge to reach the bathroom in time?

All the time

Sometimes during the day

At night from bed to bathroom

Never

8F
Do you have difficulty moving from sitting to standing postion from a commonly used chair or couch at home?

9
Current living floorplan (Check the one that most accurately describes the home layout):

Single floor no steps or stairs in home.

Single floor no steps or stairs in home, but stairs outside that are used regularly.

Multiple floors in home with at least one set of stairs that are USED REGULARLY.

Multiple floors in home with at least one set of stairs that are NOT USED.

10
Steps, Stairs, Basement: Check all that apply in the home

I have fallen or slipped on stairs in the last year.

Some steps or stairs in my home lack railings for support.

I have concerns about the stability or sturdiness of the railings.

Stairway carpet or tread covers are in bad shape or loose and can cause tripping.

Slipping on at least one current staircase is a strong possibility due to the smooth or slick surface (wood, tile, stone, etc).

Stairway lighting at night is a concern.

Items are sometimes left on stairway steps.

There are electrical cords/wires that are not secured around stairways which can cause tripping.

Basement: there are loose rugs or carpets that could cause tripping.

Basement: there are electrical cords/wires that are not secured and could cause tripping.

Basement: there are areas that are poorly lit.

Home Fall Prevention Assessment

Fall Assessment and Evaluation Input

Thank you for taking the first step towards fall prevention!