Patient’s Name: MRS O.

Variable Note Score

History of Falling
 Yes= 25 YES 25
 No= 0
Secondary Diagnosis
 Yes = 15 15
 No= 0
Ambulatory Aids
 Furniture = 30 FURNITURE 30
 Crutches, cane, walker= 15
 None, bed rest, wheelchair,
nurse assist= 0
Intravenous Therapy
 Yes= 20 NO 0
 No= 0
Gait/Transferring
 Impaired = 20 IMPAIRED 20
 Weak = 10
 Normal, bed rest = 0
Mental Status
 Understands limitations = 15 UNDERATAND 15
 Does not understand LIMITATIONS
limitations = 0
Total Score 120

HIGH RISK FOR FALL