Fall Risk Checklist for Caregivers

Brooke Phillips, CWCMS
Editor | Shield HealthCare
04/01/16  5:55 AM PST
Fall Risk Checklist

Is your loved one at a high risk for falls? Take this easy 10-question test to find out.

Fall Risk Checklist

Answer each question with “Yes” or “No” as it applies to your loved one:

1. Is the person you care for 65 or older?     Yes ____     No ____

2. Does s/he have 3 or more current health issues that have been diagnosed by a doctor?     Yes ____     No ____

3. Has s/he fallen in the past 3 months?     Yes ____     No ____

4. Has s/he had any recent incontinence episodes? This includes both daytime and nighttime leakage, as well as trouble making it to the bathroom in time.     Yes ____     No ____

5. Does the person you care for have vision problems? If s/he has a prescription for glasses or contacts, mark yes if they are not always worn around the house.     Yes ____     No ____

6. Does s/he have any difficulty with day-to-day activities such as getting dressed, brushing teeth and hair, bathing, going to the bathroom, eating or preparing meals? This includes using a cane, walker or wheelchair to move around.     Yes ____     No ____

7. Are there dimly lit areas, pets, clutter or other items in the home that can trip your loved one? This includes missing or dim light bulbs, lamp cords, medical equipment tubes, uneven floors or stairs, items that need a step stool to be retrieved, throw rugs and anything stacked on the floor or stairs.     Yes ____     No ____

8. Does s/he take 4 or more prescription drugs?     Yes ____     No ____

9. Does the person you care for experience any pain with movement? This includes both permanent pain with a specific movement, or pain that comes and goes.     Yes ____     No ____

10. Does s/he have any issues with memory or confused thinking? This includes people who show symptoms of dementia or Alzheimer’s, who are easily confused, or who seem to have poor judgment or memory.     Yes ____     No ____

Total Score:      Yes ____     No ____

*If you answered “Yes” to 4 or more questions, your loved one has a high risk of falling.

Click here for ways you can reduce your loved one’s fall risk at home: Preventing Falls at Home: A Home Safety Checklist


PrinterDownload our printable fall risk checklist in English here:

Fall Risk Checklist – English

Download our printable fall risk checklist in Spanish here:

Fall Risk Checklist – Spanish


More Fall Prevention Resources:

For additional caregiver resources and support, visit the Shield HealthCare Caregiver Community.

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