Fall-Risk Medication Worksheet
Use this sheet to discuss dizziness, sleepiness, balance, and medicines that may contribute to falls.
Page 1 of 2
What has happened?
Medicines to review 1–15
| # | Medicine | Dose / time | Symptom or concern | Plan from provider |
|---|---|---|---|---|
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Fall-Risk Medication Worksheet
Use this sheet to discuss dizziness, sleepiness, balance, and medicines that may contribute to falls.
Page 2 of 2
Medicines to review 16–30
| # | Medicine | Dose / time | Symptom or concern | Plan from provider |
|---|---|---|---|---|
| 16 | ||||
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Fall details and questions
Do not stop a medicine suddenly without professional guidance. Call 911 for severe injury, loss of consciousness, stroke signs, chest pain, or trouble breathing.