Balance & Falls Risk Evaluation (Physical Therapy)

Date of Service: [Date]

Clinician: [Name, credentials]

Setting: [outpatient clinic / home-based / hospital outpatient]

Visit Type: [initial evaluation / re-evaluation]

Referring Provider: [Name] (Omit if not applicable)

Medical Diagnosis: [ICD-10 codes from referral]

PT Treatment Diagnosis: [PT-focused diagnosis describing balance impairment and falls risk drivers]

Precautions: [Relevant precautions affecting testing and intervention] (Omit this line if none)

Chief Concern

[Patient-centered summary of primary concern with direct quote if available; clinical question prompting evaluation such as falls risk drivers, community ambulation safety, assistive device needs, or differentiating vestibular versus strength/balance limitations] (2–4 sentences)

Subjective

History & Falls Profile

[Onset and course of symptoms; primary symptom profile including imbalance, unsteadiness, vertigo, or lightheadedness; triggers and modifiers; associated symptoms if relevant; salient direct quotes]

[Falls history: number of falls in past 12 months with approximate dates; injuries and medical care required; near-falls frequency and typical situations; fear of falling and activity restriction; contextual details including footwear, device use, lighting, surface, turning] (Document source of information and note uncertainty when history is unclear)

Functional Status

[Prior and current function for transfers, household ambulation, community ambulation, and stairs/curbs; assistive devices used and where; assistance level; affected ADLs/IADLs] (Use ICF-style phrasing emphasizing activity limitations and participation restrictions)

Medical & Social Context

[Relevant comorbidities affecting balance; medication risk context without inferring causality; home environment factors; footwear considerations; support system and living situation; baseline physical activity level]

Patient Goals

• [Patient-prioritized functional goal]
• [Additional patient goal] (Include only if stated)
• [Additional patient goal] (Include only if stated)

(If subjective history is unavailable, briefly state the limitation and sources used such as chart review or prior notes)

Objective

Test Conditions & Safety

[Guarding level provided; loss-of-balance events during exam and recovery; assistive device and footwear used during testing; expected tests not performed with reasons] (Use "Not tested—[reason]" format for deferred tests)

Vitals & Systems Screening

Vitals: [Resting BP, HR] (Include orthostatic vital signs when indicated by positional symptoms: document positions, BP/HR, symptoms at each stage. Abnormal defined as SBP drop ≥20 mmHg, DBP drop ≥10 mmHg, or symptomatic dizziness)

• Neurologic: [Light touch, proprioception, coordination findings]
• Musculoskeletal: [LE strength by MMT or functional testing, ROM restrictions, postural alignment]
• Oculomotor: [Smooth pursuit, saccades, gaze-holding findings] (Include only if dizziness present)
• Foot/Ankle: [Status and footwear observation]

Gait & Mobility

• Gait: [Base of support, step length, variability/sway, turning strategy, device use]
• Transfers: [Sit-to-stand strategy, hand use, stability]
• Stairs/Curbs: [Technique, assistance/device, safety] (Include only if assessed)
• Dual-Task: [Tolerance and observed effects] (Include only if assessed)

Standardized Outcome Measures

(Document each measure with test name, raw score with units, interpretation relative to fall-risk thresholds, and non-standard test conditions if applicable. Include at least one balance measure and one gait/functional measure unless unsafe. Integrate findings with fall history rather than using single cutoffs in isolation.)

• [Measure name] — [Raw score with units]; [Interpretation vs threshold]; [Testing conditions if modified]
• [Measure name] — [Raw score with units]; [Interpretation vs threshold]; [Testing conditions if modified]
• [Measure name] — [Raw score with units]; [Interpretation vs threshold]; [Testing conditions if modified] (Add measures as appropriate)
• Not tested—[reason] (Include only for expected measures deferred)

Device & Home Safety Screening

• [Observed assistive device fit, use technique, and training needs]
• [Footwear hazards or recommendations]
• [Home safety screening findings; need for formal home assessment] (Include if available)

Assessment

[Clinical summary synthesizing primary functional problems, key objective deficits, and main fall risk drivers] (2–5 sentences; distinguish patient-reported symptoms from clinician findings)

Fall Risk Level: [low / moderate / high] — [Predominant contributors such as balance strategy impairment, sensory dependence, dynamic gait instability, LE weakness/power deficit, vestibular involvement, orthostatic hypotension, environmental/device factors]

Problem List:

• [Functional problem linked to objective findings and activity/participation limitations]
• [Functional problem linked to objective findings and activity/participation limitations]
• [Functional problem linked to objective findings and activity/participation limitations] (Add or remove as appropriate)

Prognosis: [Expected trajectory and timeframe; key influencing factors including comorbidities, cognition, adherence, and support system]

Skilled Need: [Justification for skilled PT such as safety management, clinical judgment for progression, device prescription, vestibular intervention, complex comorbidity management]

Plan of Care

Frequency/Duration: [Visits per week] for [Total weeks or visits]

Interventions: (Include only those applicable to assessed drivers)

• [Balance training: static, dynamic, sensory integration, reactive strategies]
• [Gait training: speed, turning, terrain, dual-task, community mobility]
• [Therapeutic exercise: LE strength/power, trunk control, endurance]
• [Vestibular rehabilitation: adaptation, habituation, canalith repositioning] (Include only if indicated)
• [Assistive device assessment and training]
• [Patient/caregiver education: fall prevention, environmental modifications, safe transfers]
• [Home exercise program components and progression]
• [Referral coordination: OT home safety, vision, medical evaluation for orthostasis, medication review] (Include only if indicated)

Goals:

Long-term goals: (Functional, measurable, time-bound; specify assist level, device, environment)

• [Functional goal linked to baseline measure with targeted improvement and timeframe]
• [Additional long-term goal] (Include only if applicable)

Short-term goals:

• [Interim performance metric or functional milestone with timeframe]
• [Additional short-term goal] (Include only if applicable)

Discharge Planning: [Expected discharge criteria; transition plan such as community program, independent HEP, caregiver training; reassessment intervals for key measures]

Communication: [Plan transmission to referring provider; findings requiring medical follow-up such as abnormal orthostatics, neurologic red flags, suspected BPPV, unsafe home environment] (Omit if no communication needed beyond routine plan transmission)