Morse Fall Scale Assessment
Please complete the following assessment to evaluate the patient's fall risk using the Morse Fall Scale.
Patient Name
*
First Name
Last Name
Date of Assessment
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diagnosis
*
Facility Name / Care Home
*
History of Falling
*
No previous fall
Fall within past 3 months
Fall within past 6 months
Fall within past year
Secondary Diagnosis
*
Please Select
None
Chronic illness
Recent surgery
Other
Ambulatory Aid
*
None
Walker
Cane
Crutches
Wheelchair
Immobility / Medication Lock
*
No
Yes
Gait / Transferring
*
Normal
Weak
Impaired
Unsteady
Mental Status
*
Alert and Oriented
Disoriented
Confused
Unresponsive
MFS Score
*
Risk Level
*
Please Select
No Risk
Low Risk
High Risk
Comments and Observations
Assessed By (RN)
*
First Name
Last Name
Patient signature
*
Submission by Authorized Representative
*
Patient
Behalf of patient
Should be Empty: