Falls Assessment and Education Service Self-Referral Form

Your Details

Name *
Please input your name

Address 1 *
Please input the first line of your address

Address 2

Town *
Please input your town

Postcode *
Please input postcode

Telephone Number
Please input valid telephone number

Date of Birth *
/ / Please enter patient's date of birth

NHS No
Please input patient's NHS Number

GP Name
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GP Surgery *
Please input GP Surgery

GP Address
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GP Tel No *
Please input valid GP telephone number

Gender
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Ethnicity *
Please select one answer

Communication Requirements

Do you need any additional help with reading/listening/speaking?
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Please detail help required
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Falls History

How many falls have you had in the last 12 months? (this is to make sure you are contacted by the correct team) *
Please input number of falls

Please describe your last fall, e.g. where you were, what time of day, what happened? *
Please input history of last fall

What do you think caused you to fall? (please select all that apply)

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Please detail other cause for your fall
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Your Mobility

Do you have any problems with balance?
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Do you have difficulty getting up from a chair?
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Do you have difficulty getting off the floor?
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Do you use anything to help you walk?
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If you do use anything to help you walk, please tell us what you use
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Do you live alone?
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Please tell us who you live with
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Are any other health or support services currently involved in your care? e.g. reablement, carers, community nursing
(this is to know how much outside support you already have, if any)
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Appointment Details

Are you able to attend an outpatient appointment?
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If yes, where would you like to be seen?
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Please tell us more about why you are unable to attend
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You will be contacted to discuss the referral. If you would prefer us to speak to someone else, please tell us who would be the best person to contact and their telephone number
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