Fall or near-fall timing Same day fall or near fall Recent fall without a clear follow-up plan After ER, urgent care, or hospital visit Repeated falls or near falls Near fall, stumble, or balance scare
Injury or symptom concern No obvious injury known Minor soreness, scrape, or bruise Pain, swelling, bruising, or limited movement Head hit, dizziness, fainting, confusion, or blood thinner concern Walking, transfers, stairs, or confidence changed
Fall pattern First known fall or near fall More than one fall or near fall Not sure or details are incomplete
Medical follow-up status No follow-up scheduled yet Follow-up is scheduled Follow-up happened and tasks need organizing Not sure what follow-up is needed
Medicine review status Medicines not reviewed after the fall Medicine changed recently Pharmacist or clinician review may help Not sure which medicine list is current
Home safety concern to check first Home setup not reviewed yet Bathroom, shower, stairs, or handrails Lighting, rugs, cords, clutter, or pathways Walker, cane, footwear, bed, chair, or transfers
Mobility confidence now Mostly steady Cautious but moving around Fear of falling is limiting activity Needs more help with walking or transfers
Caregiver or support coverage Lives alone or has limited check-ins Family or friends can check in Paid caregiver or agency involved Assisted living, rehab, nursing home, or other facility
Local fall-prevention support Not contacted yet Looking for classes, transportation, or home help Connected to local support already
Next visit to prepare for Primary care or clinic follow-up Medicare yearly Wellness or prevention visit Specialist, therapy, rehab, or facility review Not sure where to start
Use broad, non-identifying planning answers only.
Do not enter names, addresses, birth dates, diagnoses, Medicare numbers, Social Security numbers, account numbers, medication details, or private medical records. Keep the real fall note and care records in a secure place.
This planner is educational and organizational only. It is not medical, legal, insurance, benefits, emergency-response, or care-management advice. For urgent symptoms, suspected injury, head injury concerns, confusion, fainting, severe pain, trouble walking, or immediate danger, contact emergency services or qualified medical care.
Official references:
CDC falls facts ,
NIA falls and fractures ,
Medicare yearly Wellness visits ,
Eldercare Locator .
