Fall Risk Assessment
Professional Fall Risk Assessment template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Fall Risk Assessment
TEMPLATE • Inspection-Ready AFH Standard
1. Fall History & Medical Risk Factors
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Standardized Risk Scoring Scale
FINANCIAL TERMSBase Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
3. Individualized Fall Intervention Plan
Provider Signature / Date
Resident / POA Signature / Date
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Document Section Breakdown (4 Sections)
Fall History & Medical Risk Factors
Previous falls, medications affecting balance, gait stability, and vision status.
Standardized Risk Scoring Scale
Numeric risk scoring matrix (Morse/Hendrich adaptation for AFH setting).
Individualized Fall Intervention Plan
Bed alarms, non-slip footwear, transfer assistance level, and environment safety.
Re-Assessment Schedule & Signatures
Quarterly review log and post-fall reassessment requirements.
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