| Item | Score | ||
| 1. History of falling | No | 0 | |
| Yes | 25 | ||
| 2. Secondary diagnosis | No | 0 | |
| Yes | 15 | ||
| 3. Ambulatory aid | |||
| None/bed rest/nurse assist | 0 | ||
| Crutches/cane/walker | 15 | ||
| Furniture | 30 | ||
| 4. Intravenous therapy/saline lock | No | 0 | |
| Yes | 20 | ||
| 5. Gait | |||
| Normal/bed rest/wheelchair | 0 | ||
| Weak | 10 | ||
| Impaired | 20 | ||
| 6. Mental status | |||
| Oriented to own ability | 0 | ||
| Overestimates/forgets limitations | 15 | ||
| Total | |||
