PLEASE READ: When We Receive Your Referral

Priority: High/Medium/Low Level III Falls Service For Office Use Only

EAST RIDING FALLS SERVICE REFERRAL FORM 1 MOST RECENT FALL Circumstances: Where? Why? What were you doing at time of your fall? When?

2a How many falls in the last 6 months and circumstances around these falls.

2b Any associated injuries: Bruises # (Broken Bones)

2c History of Collapse, Loss of consciousness or blackouts?

3 MAIN HEALTH PROBLEMS

4 AIDS & ADAPTATIONS (eg: stair lift, walk in shower, grab rails etc.)

5 BALANCE (eg: unsteady on feet, dizziness, use of any walking aids)

6 REFERRER PLEASE INDICATE ADVICE GIVEN TO MINIMISE FALLS RISKS: FOR EXAMPLE

Optician Ref made Advice against inappropriate footwear

Referred for Life Line Removed loose rugs/carpets

Referred for Medication review Other – explain

7 Additional Comments

PLEASE READ: When we receive your Referral:

Once we have received your referral form it will be prioritised, based on the information you provide. Intervention is based on need, where some patient may only require advice, and other may need a combination of both advice and intervention. Please ensure all sections are completed.