This resource was developed by bpac
nz
for the Health Quality & Safety Commission based on the STEADI falls campaign by the US Centres for Diseases Control and Prevention (CDC).
Patient name: Date: Time: AM/PM
NHI: Clinician:
Falls Risk Factor Checklist
Screening History
Any trips, slips, falls (or near falls) in past year?
Yes
No
Can’t get out of a chair without using their
hands?
Yes
No
Limits or avoids activities because afraid of losing
balance or falling?
Yes
No
Falls Risk Factor Identied Factor present? Notes/Actions taken
Feels unsteady when standing or walking?
Yes
No
Timed Up and Go (TUG) Test
≥12 seconds
Yes
No
30-Second Chair Stand Test
Below average score (See table on back)
Yes
No
Four-Stage Balance Test
Heel-Toe stance <10 seconds
Yes
No
At risk of vitamin D deciency?
Yes
No
Foot problems?
Yes
No
Inadequate or improper footwear?
Yes
No
Any psychoactive medicines, medicines with
anticholinergic side eects, medicines that
decrease blood pressure or sedatives?
Yes
No
Any dizziness?
Yes
No
A decrease in systolic BP ≥ 20 mm Hg, or a
diastolic BP of ≥ 10 mm Hg, or light-headedness
or dizziness from lying to standing?
Yes
No
Cognitive impairment?
Yes
No
Acuity < 6/12 OR no eye exam in > 1 year?
Yes
No
Continence or urgency problems?
Yes
No
Problems with heart rate and/or rhythm?
Yes
No
Depression?
Yes
No
Other medical conditions or risk factors (specify)
Yes
No
ACT
