Custodia Fall Risk Assessment
Use this assessment to find and fix the hazards for every area in your home that might cause you to trip or fall. All items are risks for potential falls, though some may not apply if a wheelchair is used. For an expedited evaluation, access only places that you use frequently.

This is a detailed assessment that will take 20-30 minutes to complete.

You will get a score and a detailed list of action items at the end of the assessment.

Higher Points = Lower Fall Risk
Lower Points = Higher Fall Risk

Message service@custodia.com to get your fall prevention assessment done in person or over the phone.

The results of this Fall Risk Assessment will be emailed to you. Please provide your email below.
Sign in to Google to save your progress. Learn more
Email *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Custodia. Report Abuse