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Professional Fall Risk Assessment template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
TEMPLATE • Inspection-Ready AFH Standard
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
Base 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.
Provider Signature / Date
Resident / POA Signature / Date
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Previous falls, medications affecting balance, gait stability, and vision status.
Numeric risk scoring matrix (Morse/Hendrich adaptation for AFH setting).
Bed alarms, non-slip footwear, transfer assistance level, and environment safety.
Quarterly review log and post-fall reassessment requirements.
Or get this form included in the AFH Starter Kit ($129)