Free Nursing Home Health Risk Assessment Form

Assess health risks effectively with the Nursing Home Health Risk Assessment Form Template from Template.net. This editable and customizable template simplifies the process of evaluating residents' health conditions and identifying potential risks. Tailor it effortlessly using our Ai Editor Tool for personalized assessments. Enhance resident care and ensure comprehensive risk management with this essential template.

Resident Details
Full Name:
Date of Birth:
Gender:
Address:
Phone Number:
Emergency Contact:
Emergency Contact Number:
Relationship to Resident:
Healthcare Proxy (if applicable)
Healthcare Proxy Name:
Relationship to Resident:
Contact Number:

Falls Risk
History of Falls:	Yes No
Mobility Status:	Low Moderate High
Assistive Devices in Use:	Yes No
Environmental Hazards Identified:	Yes No
Previous Falls Risk Assessment Scores (if available):	[0]
Pressure Ulcer Risk
Braden Scale Score:	[0]
Mobility:	Impaired Limited Normal
Skin Condition:	Healthy Compromised
Previous History of Pressure Ulcers:	Yes No
Nutritional Risk
BMI (Body Mass Index):	[0]
Weight Change in Past Month:	[0]
Appetite:	Good Fair Poor
Dietary Restrictions:	Yes No
Infection Risk
Immunization Status:	Up to Date Not Up to Date
History of Recent Infections:	Yes No
Skin Integrity:	Intact Compromised

Free Nursing Home Health Risk Assessment Form

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Nursing Home Health Risk Assessment Form

Personal Information

Health Information

Medical History

Functional Status

Risk Assessment

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