Fall Risk Assessment Form
Fall risk assessment recording fall history, mobility and balance, medications, vision, and home hazards, with a plan for follow-up and referrals.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 16 questions, 3 pages, 1 conditional rules.
- Questions
- 16
- Pages
- 3
- Layouts
- classic · card
- Time to complete
- ≈ 7 min
- Conditional rules
- 1
Searches this template answers
- fall risk assessment form
- fall risk screening form
- home safety fall assessment
- elderly fall risk form
- fall prevention assessment form
- patient fall history form
Also filed under
Live preview and test console
This is the real form. Answer it to test the 1 conditional rule — nothing is sent or stored.
Page 1 of 3 — About the patient
1 question is hidden by conditional logic right now — change an answer above to reveal it.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
Who this template is for
Fall Risk Assessment Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 16 questions across 3 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 12 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It records a signature you can keep as proof of agreement.
- It pins the request to a specific date.
- It allows multiple selections without free text.
- Conditional logic hides 1 question until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 3 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Fall Risk Assessment Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 1 conditional rule ship with it.
- Features advanced show logic: if “Has the patient fallen in the past 12 months?” is Yes, the form dynamically exposes “Describe the most recent fall, including where and how it happened”. Otherwise that question never appears.
- All 1 rule are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
About this template
A fall risk assessment works best as a written record of what was actually observed and reported, not a guess made from memory after the visit. This form starts with the patient's fall history over the past year, since a prior fall is one of the clearest things a clinician wants on file, and opens a short description box only when a fall is reported. The second page covers mobility and health factors that commonly relate to falls: any walking aid in use, difficulty with balance, vision problems, current medications, and reported dizziness or lightheadedness. The last page turns to the home environment itself, recording hazards such as stairs, loose rugs or poor lighting, whether the patient lives alone, and which prevention measures are already in place, before closing with the assessor's recommended next steps and signature. The form does not calculate a risk score; it documents what was seen and reported so the care team can decide what to do about it.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — About the patient
- Patient full namerequired
- Date of birthrequired
- Assessed byrequired
- Has the patient fallen in the past 12 months?required
- Describe the most recent fall, including where and how it happened
Page 2 — Mobility and health factors
- Walking aid usedrequired
- Any difficulty with balance or walking?required
- Vision problems affecting mobility?required
- Current medications
- Reports dizziness or lightheadedness?required
Page 3 — Environment and plan
- Home environment hazards noted (stairs, rugs, lighting, clutter)
- Does the patient live alone?required
- Fall prevention measures already in place
- Recommended next steps or referralsrequired
- Assessor signaturerequired
- Date signedrequired
16 questions in total.
Example of a completed fall risk assessment form
A sample assessment showing how a patient's fall history and mobility are recorded during a home visit.
- Patient full name
- Edith Marlow
- Assessed by
- Priya Nair, RN
- Has the patient fallen in the past 12 months?
- Yes
- Describe the most recent fall, including where and how it happened
- Slipped on the bathroom floor reaching for a towel, six weeks ago
- Walking aid used
- Cane
- Any difficulty with balance or walking?
- Yes
- Vision problems affecting mobility?
- Yes
- Reports dizziness or lightheadedness?
- No
- Does the patient live alone?
- Yes
- Fall prevention measures already in place
- Adequate lighting
- Recommended next steps or referrals
- Refer for physical therapy and install grab bars in the bathroom
Sample data — no real people, addresses or records are shown. This example makes no claim about any individual's actual risk.
How the form changes as it's filled in
This template ships with 1 conditional rule, grouped into 1 behaviour driven by 1 question. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Has the patient fallen in the past 12 months?”
- Reveals questions
If “Has the patient fallen in the past 12 months?” is Yes, the form reveals “Describe the most recent fall, including where and how it happened”.
Set it up step by step
- 1
Ask about the fall itself, not just whether one happened
Where and how a fall happened tells the care team more than a yes-or-no answer ever will.
- 2
Read medications with the fall history side by side
A recent medication change and a recent fall together are worth flagging to the prescriber before the next dose round.
- 3
Walk the home before finishing the plan
Hazards reported by a family member are useful, but a short walk-through catches things nobody thought to mention.
- 4
Set a review date
A fall risk assessment filed once and never revisited misses a change in condition; put a follow-up date on the plan.
Mistakes to avoid
- Recording only whether a fall happened, with no detail on the circumstances.
- Leaving the medication list generic instead of noting anything sedating or new.
- Skipping the home environment section for a patient assessed in a clinic rather than at home.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Share flagged answers with the prescribing clinician, arrange any referrals noted in the plan, and schedule a follow-up assessment on the timeline the assessor set.
Works in both layouts
Forms that overlap this one
These pages cover the same subject ground as the fall risk assessment form, matched on the words people actually search for.
Patient History Form
clinicclinicalhealthhistoryintake
Home Health Assessment
assessmentclinicclinicalhazardhealth
Discharge Follow-Up Form
clinicclinicalfollowhealthhistory
Medical History Form
healthhistoryintakemanagermedical
Caregiver Assessment Form
assessmentcaseclinicclinicalhealth
Occupational Health Form
assessmentclinicclinicalhealthhistory
Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
Does this form produce a risk score?
No. It records the history, factors and observations an assessor gathered; scoring or grading them is left to your clinical process, not this form.
Can it be used in a clinic instead of at home?
Yes, though the environment section works best completed during an actual home visit, since a description given secondhand is less reliable.
Who should complete the environment section?
Whoever conducts the home visit, ideally after walking through the areas the patient uses most, rather than relying only on what the patient reports.
How often should this be repeated?
That depends on your program's policy and the patient's condition; set the review date on the form itself so it does not get missed.
Is the Fall Risk Assessment Form template free to use?
Yes. You can preview and test Fall Risk Assessment Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Fall Risk Assessment Form template ask for?
It asks 16 questions across 3 pages, 12 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Fall Risk Assessment Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
1 conditional rule ships with the template: Features advanced show logic: if “Has the patient fallen in the past 12 months?” is Yes, the form dynamically exposes “Describe the most recent fall, including where and how it happened”. Otherwise that question never appears. All 1 rule are editable in the Logic tab, and the built-in checker warns about rules that contradict each other. All rules are editable in the Logic tab.
Where do responses to the Fall Risk Assessment Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Fall Risk Assessment Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Is the signature on this form legally usable?
The template captures a drawn signature and stores it with the submission, along with the timestamp, so you keep evidence of who agreed and when. Whether that is sufficient depends on your jurisdiction and the agreement itself.
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