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Care Home Risk Assessment Example Form
Months)
Orthostatic
Changes
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4
G.
Medications
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Patient Status/Condition
Alert and oriented X3
Disoriented X 3 at all times
Intermittent confusion
No falls
1-2 falls
3 or more falls
Ambulatory & continent
Chair bound & requires assist w/ toileting
Ambulatory & incontinent
Adequate (w/ or w/o glasses)
Poor (w/ or w/o glasses)
Legally blind
Have patient stand on both feet w/o any type of assist then have walk: forward,
thru a doorway, then make a turn. (Mark all that...
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