| Age | 70-79 y Greater than or equal to 80 y |
| Fall History | Fall within 3 months before admission Fall during this hospitalization |
| Mobility | Ambulates or transfers with unsteady gait and NO assistance or assistive devices Ambulates or transfers with assistance or assistive device Visual or auditory impairment affecting mobility |
| Elimination | Urgency/nocturia Incontinence |
| Mental status changes | Affecting awareness of environment Affecting awareness of one's physical limitations |
| Medications |
☐sedated procedure within the past 24 h ☐Psychotropics (antidepressants, hypnotics, antipsychotics, sedatives, benzodiazepines, some antiemetics) ☐Anticonvulsants ☐Diuretics/cathartics ☐PCS/narcotics/opiates ☐Antihypertensives |
| Patient care equipment |
☐IV ☐chest tube ☐indwelling catheter ☐SCDs |
Fall risk factor category *
(NA If comatose, complete paralysis, or completely immobilized)
*Moderate risk = 6-10 Total points, High risk > 10 Total points