Download Falls Service Referral Form 2014 - Croydon Health Services NHS

FALLS SERVICE REFERRAL FORM
In order for the referral to be processed, please attach recent medical summary and list of
medications & complete form.
Falls Service home assessment:
(Assessment including OT and PT)
(tick)
Falls Service Clinic assessment:
(Medical assessment by Falls
(tick)
Consultant – By GP referral ONLY)
Falls Service Bone
Health Specialist Nurse
assessment:
(tick)
Please fax to: 0208 274 6885 OR E-mail: [email protected]
Service Criteria
Patient MUST be 65 years and above with
 >2 falls within the last 12 months,
Or
 1 episode of fall that has led to a hospital
admission/ injuries
and
 New or worsening gait/balance deficits
Or
 Unexplained falls with apparent complex
medical cause or loss of consciousness
NHS Number:
Surname
Address:
Preferred Language:
NEXT OF KIN DETAILS
Full Name:
Bone Health Specialist Nurse Criteria
Women and men who had suffered a recent or previous fragility
fracture sustained at age 50 or above AND in the presence of risk
factors, namely:

Current or frequent use of oral or systematic glucocorticoids,
or

History of falls, or

Family history of hip fracture, or

Other causes of secondary osteoporosis, or

Low body mass index (BMI) (less than 18.5kg/m2), or

Smoking, or

Alcohol intake of more than 14 units per week for women
and more than 21 units per week for men
PATIENT DETAILS
Epex Number:
/
Forename(s)
Telephone Number(s)
Work:
Mobile:
Home:
Interpreter required?
Ethnicity:
Date of Birth
/
Gender:
/
Yes / No
GP DETAILS
Name and Practice:
Relationship to Patient:
Address (including postcode):
Telephone Number:
Address:
Contact Number (s):
When was the last fall:
How many falls in the last year:
PATIENT INFORMATION
Medical History / Symptoms
Arthritis / Foot deformity
Chest Pain / Palpitations
(new onset or recently worsening)
Can they go outdoors alone: Yes / No
Can they stand from a chair independently:
Yes / No
Year of the last fracture (for Bone Health Specialist Nurse):
Cognitive Impairment
Dizziness / Vertigo
Gait Problems
Loss of Consciousness
Osteoporosis / Previous Fractures
Seizures (witnessed)
SOB (new onset or recently worsening)
Visual Impairment
Are there any specific medical concerns that may
contribute to the fall (e.g. COPD / Diabetes / Angina /
Depression):
Medication – on any of the following:
Antidepressant / antipsychotic
Anti-hypertensive (more than 1)
Bone protection
Diuretics
Opiates
Sedatives
Reason for Referral / Presentation of fall / Impact on patient:
Recent Hospital Admission/ A/E attendance:
Reason for admission:
Date of Discharge:
Yes
No
Name and address:
Profession:
REFERRER DETAILS
Telephone / Fax:
Recent medical summary and list of medications attached
Date and Time of Referral:

NOTE: AGE-UK is part of the Falls Service within the community and referrals (if appropriate) may be made to
them by the Falls Therapists only for a basic environmental check with the consent of the patient.