FALLS RISK ASSESSMENT
State Form 53502 (R / 11-09)
FAMILY & SOCIAL SERVICES ADMINISTRATION
MADISON STATE HOSPITAL
□ Admission □ Annual □ Post-Fall □ Other _________________
Circle appropriate score for each section and total score at bottom.
Level of Consciousness/
Mental Status
History of Falls
(past 3 months)
Ambulation/
Elimination Status
Chair bound & requires assistance with toileting
Adequate (with or without glasses)
Poor (with or without glasses)
Have patient stand on both feet w/o any type of assist then have walk: forward, thru a
doorway, then make a turn. (Mark all that apply.)
Normal/safe gait and balance.
Balance problem while standing,
Balance problem while walking.
Decreased muscular coordination.
Change in gait pattern when walking through doorway.
Jerking or unstable when making turns.
Requires assistance (person, furniture/walls or device).
No noted drop in blood pressure between lying and standing.
No change to cardiac rhythm.
Drop<20mmHg in BP between lying and standing.
Increase of cardiac rhythm <20.
Drop >20mmHg in BP between lying and standing.
Increase of cardiac rhythm>20.
Based upon the following types of medications: anesthetics, antihistamines, cathartics,
diuretics, antihypertensive, antiseizure, benzodiazepines, hypoglycemic, psychotropic,
sedative/hypnotics.
None of these medications taken currently or w/in past 7 days.
Takes 1-2 of these medications currently or w/in past 7 days.
Takes 3-4 of these medications currently or w/in past 7 days.
Mark additional point if patient has had a change in these medications or
doses in past 5 days.
Based upon the following conditions: hypertension, vertigo, CVA, Parkinsons Disease,
loss of limb(s), seizures, arthritis, osteoporosis, fractures.
Inappropriate or client does not consistently use assistive device.
Score of 8 to 14 = Moderate risk for falls
Score of 15 or Above = High risk for falls
If score is 8 or above, the back page of this form must be completed.
Patient has been informed about fall risk assessment results and/or safety/fall prevention recommendations:
□ Yes □ No
Addressograph
