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.

Describe the circumstances and cause of fall(s)? Place, situation, surroundings, room, what activity was in progress (walking, reaching, getting out of shower, stairs, etc.).

8
Check all the statements that apply:

I’m concerned about a serious fall happening in the next year.

Uses or has been advised to use a cane or walker to get around safely.

Feels unsteady when walking.

Steadies body by holding onto furniture when walking around home.

Needs to use hands to push stand up from something (chair, table, etc.).

Noticeably has trouble stepping up onto a curb.

Takes medicine that sometimes causes light-headedness or feeling more tired than usual.

9
Current living situation:

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
Check all that apply regarding in the home:

Has fallen or slipped on stairs in the last year.

Some steps or stairs 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 could cause tripping.

Slipping on at least one current staircase is a strong possibility due to the smooth or slick surface.

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 and could 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.

Basement: There are frequently used items in kitchen that are difficult to reach or get to easily (low or high).

Home Fall Prevention Assessment

Fall Assessment and Evaluation Input