| Question | Response |
|---|---|
| Did the patient fall since last visit? | No Yes Unknown |
| Date of fall | |
| Time of the day | MORNING AFTERNOON EVENING NIGHT UNKNOWN |
| Environment (of fall) | AT HOME: INSIDE AT HOME: OUTSIDE AWAY FROM HOME: FAMILIAR PLACE AWAY FROM HOME: STRANGE PLACE UNKNOWN |
| Activity at the time of fall | WALKING CHANGING POSITION STAIRS PHYSICAL ACTIVITY OTHER |
| Fall Mechanism | TRIPPING SLIPPING STAIR FALL FALL FROM AN UPPER LEVEL OTHER EXTRINSIC MECHANISM INTRINSIC MECHANISM |
| Did the fall result in injury | No Yes |
| Severity of the injury | MINOR INJURY NOT REQUIRING MEDICAL ATTENTION MODERATE INJURY REQUIRING MEDICAL ATTENTION SEVERE INJURY REQUIRING EMERGENCY OR INPATIENT THERAPY |