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Hendrich II Fall Risk Model(NM301041)

Hendrich II Fall Risk Model(NM301041) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires

 




Patient Name

DOB:

MR #


NM301041 (Rev. 09/27/16) Worksheet Only – Not a Medical Record Document
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
HENDRICH II FALL RISK MODEL™







Confusion
Disorientation
Impulsivity

4

Symptomatic
Depression

2

Altered
Elimination

1

Dizziness
Vertigo

1

Male
Gender

1

Any
Administered
Antiepileptics
2

Any
Administered
Benzodiazepines

1
Get Up & Go Test

Able to rise in a single movement – No loss of balance with steps
0
Pushes up, successful in one attempt
1
Multiple attempts, but successful
3
Unable to risewithout assistance during test (OR if a medical order
4

A Score of 5 or Greater = High Risk Total Score

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Reproduction and use prohibited except by written permission from AHI of Indiana Inc.