A fall risk screening for older adults: seventeen 1–5 statements across balance & stability, home environment and medication factors, scored into a personal profile with a printable AI PDF report and practical prevention steps.
Quick answer
An elderly fall risk assessment scores balance and stability, home environment hazards and medication-related factors on 1–5 self-ratings, and produces a personal AI PDF report showing which of the three levers — body, home or medicines — to address first.
Disclaimer: this page and its AI report are for self-reflection and process reference only. They do not constitute medical, psychological, financial, legal or safety advice. Consult a qualified clinician before making care decisions.
Methodology: items are a structural adaptation of widely used clinical frameworks, not an official validated instrument; scores are indicative, not diagnostic.
Falls rarely have one cause. This screening splits the risk into three scored dimensions: physical balance and confidence, the hazards of the living space, and medication side effects like drowsiness or dizziness. The report turns them into a ranked prevention plan — and a QR opens an AI consultant for follow-up questions.
Sample form, AI PDF report and AI consultant — fill the form to unlock all three.
Everything you need to run this template.
From copy to deliverable in four steps.
Copy the form and its scoring, report and branding settings into your FormLM workspace — free.
Adjust fields, options and consent language to match your clinic workflow.
Send the link or QR; every response is captured automatically.
Open the personalized AI PDF report and share it with the patient or the chart.
Pick your role — see how it fits your clinic workflow.
Screen residents before planning support.
A structured check before the next fall happens.
Prioritise home-safety visits by score profile.
What makes this template work as a professional clinical deliverable.
A preview of real statements respondents rate — the full version scores each answer 1–5 across three dimensions and generates a personalized, printable AI PDF report per respondent.
