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Fall Risk and Incontinence Survey for Women
 
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  Fall Risk and Incontinence Survey For Women  

 
  Women over the age of 65 are screened at least once per year with a two question screen regarding problems with bladder leakage and a two question screen regarding problems with balance or history of a recent fall. Positive screens are given a full fall risk assessment form to complete and have a sitting and standing blood pressure done when rooming the patient.
 
 
 
1.
*
 
 
 
 
2.

  mm/dd/yyyy
 
 
 
3.

  mm/dd/yyyy
 
 
 
  Fall Risk
 
 
 
4.

(please check either Yes or No)
 
 
 
 
5.

(please check YES or NO)
 
 
 
 
  If the answer to both questions is No, go to the questions on Urinary Incontinence. If the answer to either question is Yes, please answer the following questions:
 
 
 
6.

 
 
 
 
7.

 
 
 
 
8.

 
 
 
 
9.

 
 
 
 
10.

 
 
 
 
11.

 
 
 
 
12.

 
 
 
 
13.

 
 
 
 
14.

 
 
 
 
  Urinary Incontinence
 
 
 
15.

 
 
 
 
16.

 
 
 
 
  If the answer to number 1 is YES, please complete the following:
 
 
 
17.

 
 
 
 
18.

 
 
 
 
19.

 
 
 
 
  All Responses Are Confidential. Thank You!
 
 
  Done