Survey logo
Fall Risk Survey for Men
 
Page 1 of 1
 
  Fall Risk Survey For Men  

 
  Men over the age of 65 are screened at least once per year with 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 you have completed the survey, Thank you. If the answer to either question is Yes, please answer the following questions:
 
 
 
6.

 
 
 
 
7.

 
 
 
 
8.

 
 
 
 
9.

 
 
 
 
10.

 
 
 
 
11.

 
 
 
 
12.

 
 
 
 
13.

 
 
 
 
14.

 
 
 
 
  All Responses Are Confidential. Thank You!
 
 
  Done