Falls Prevention Programme

Have you been seen in the past 12 months by a Falls Prevention Service? *

Yes
No

Title *

Name *

First

Last

Preferred Name

Date of Birth *

Permanent Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Current Address (if different from above)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Do you live alone *

Yes
No

If you have answered "No", who do you live with?

Home Tel. No.

Mobile Tel. No.

Gender *

Male
Female
Transgender
Prefer not to say

Ethnicity *

Preferred Language/Main Language spoken (please specify) *

Will you require an interpreter? Please note that we are unable to provide this service but you are welcome to bring your own interpreter. *

Yes
No

Do you have any communication needs? *

Yes
No

Emergency Contact Name *

Emergency Contact Relationship (e.g. Husband, Wife, Partner, Friend) *

Emergency Contact Tel. No. *

GPs Name (if known)

GP Surgery Address *

Are you happy for us to contact your GP regarding your fitness to exercise? *

Yes
No

How would you travel to the classes? *

If you are using Dial-a-Ride, please provide your Dial-a-Ride number below.

How many falls have you had in the past 12 months? *

How often are you falling and where to you fall?

Have you sustained any fall related injuries? *

Yes
No

If you answered "Yes", please give details

If you have not had any falls yet but are worried about falling, please select all of the following issues which are affecting you

Please give further details

Have you recently undergone a surgical procedure? *

Yes (please give details below)
No

Date of procedure

Please give details of procedure

Past Medical History *

Medications (including over-the-counter medication) *

Current Level of Function

How do you get around? (Select all that apply) *

Are you independent with Activities of Daily Living (ADLs)? e.g washing, dressing *

Yes
No

Do you have a package of care? *

None
Once a day
Twice a day
Three times a day

Do you have any other equipment at home to help with your function? *

Yes
No

Name below months?

If you answered "Yes" - please specify below

Do you attend other social activities (e.g. day centres, clubs)? *

Yes
No

If you answered "Yes" - please specify below

What would you like to gain from the classes? *

Your Assessment

Current Level of Function

Falls Efficacy Scale will be sent to you to complete before you start the classes.