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Fall Risk Screen Tug

This document contains information about screening patients for fall risk. It includes questions to ask patients about their history of falls and balance issues. Patients who answer yes to any screening questions require further evaluation. The document also describes the Timed Up and Go test, which measures the time it takes a patient to stand up from a chair, walk 3 meters, turn, and return to sitting. A time of 12 seconds or more indicates a high risk of falls. The test is used to observe a patient's gait, balance, and mobility.

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138 views

Fall Risk Screen Tug

This document contains information about screening patients for fall risk. It includes questions to ask patients about their history of falls and balance issues. Patients who answer yes to any screening questions require further evaluation. The document also describes the Timed Up and Go test, which measures the time it takes a patient to stand up from a chair, walk 3 meters, turn, and return to sitting. A time of 12 seconds or more indicates a high risk of falls. The test is used to observe a patient's gait, balance, and mobility.

Uploaded by

Roger
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Patient Name: Date:

Patient ID #

Fall Risk Screening Questions

1. Have you had two or more falls within the past 12 months?  Yes No

2. Have you had a fall with injury?  Yes No

3. Do you have any problems with gait or balance?  Yes No

Patients who answer “yes” to any of the screening questions need further evaluation to
determine their fall risks. Having fallen in the past year is a strong predictor for future falls.

Older persons reporting only a single fall and reporting or demonstrating no difficulty or
unsteadiness during the evaluation of gait and balance do not require a fall risk assessment.1

The Timed Up and Go (TUG) Test

Timed Up and Go Score:


An older adult who takes ≥ 12 seconds to complete the TUG is at high risk for falling.2

1. http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recom mendations/2010
2. https://www.cdc.gov/steadi/pdf/tug_test-a.pdf
Patient: Date: Time: AM/PM

The Timed Up and Go (TUG) Test

Purpose: To assess mobility


Equipment: A stopwatch
Directions: Patients wear their regular footwear and can use a walking
aid if needed. Begin by having the patient sit back in a standard arm
chair and identify a line 3 meters or 10 feet away on the floor.

Instructions to the patient:


When I say “Go,” I want you to:
1. Stand up from the chair
2. Walk to the line on the floor at your normal pace
3. Turn
4. Walk back to the chair at your normal pace
5. Sit down again

On the word “Go” begin timing.

Stop timing after patient has sat back down and record.

Time: _________ seconds


An older adult who takes ≥12 seconds to complete the TUG is at
high risk for falling.

Observe the patient’s postural stability, gait, stride length, and sway.
Circle all that apply: Slow tentative pace  Loss of balance 
Short strides  Little or no arm swing  Steadying self on walls 
Shuffling  En bloc turning  Not using assistive device properly
Notes:

For relevant articles, go to: www.cdc.gov/injury/STEADI

Centers for Disease


Control and Prevention
National Center for Injury
Prevention and Control

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