| RPT |
| Hendrich II Fall Risk Model| | Date Given: <.Date Given.>| Clinician: <.Staff: Ordered By.>| Location: <.Location.>| | Veteran:
<.Patient Name: Last, First.>| SSN: <.Patient: SSN.>| DOB: <.Patient: Date Of Birth.> (<.Patient: Age.>)| Gender
: <.Patient: Gender.>| | | Confusion/Disorientation/Impulsivity| <*Answer_5453*>
| Depression| <*Answer_5454*>| Altered elimination| <*Answer_5455*>| Dizziness/vertigo| <*Answer_5456*>| Gender
| <*Answer_5457*>| Any prescribed antiepileptics| <*Answer_5458*>| Any prescribed benzodiazepines| <*Answer_5459*>
| Get-up- go Test Item #2: "Rising from chair"| <*Answer_5460*>
| | ------------------------------------------------------------------| A score of 5 or greater indicates high risk.| | Hendrich II Fall Risk Score: <-Fall Risk Score->| | | | | $~
|
