Download FRAT (Falls Risk Assessment Tool)

FRAT
(Falls Risk Assessment Tool)
For completion by PSI Student
By falling we mean 'a sudden unintentional change in position causing one to land on a lower level’.
Notes for users:
1) Complete assessment form below. The more positive factors, the higher the risk for falling.
2) If there is a positive response to three or more of the questions on the form, then please see
over for guidance for further assessment, referral options and interventions for certain risk
factors.
3) Some users of the guidance may feel able to undertake further assessment and appropriate
interventions at the time of the assessment.
4) Consider which referral would be most appropriate given the patient's needs and local
resources.
NAME _______________________
DATE OF BIRTH ___________
YES
1
Is there a history of any fall in the previous year?
How assessed? Ask the person.
2
Is the patient/client on four or more medications per day?
How assessed? Identify number of prescribed medications.
3
Does the patient/client have a diagnosis of stroke or Parkinson's
Disease?
How assessed? Ask the person.
4
Does the patient/client report any problems with their balance?
How assessed? Ask the person.
5
Is the patient/client unable to rise from a chair of knee height?
How assessed?
Ask the person to stand up from a chair of knee height without
using their arms.
NO
HEALTH QUESTIONNAIRE
Name:
Date of birth: ____/____/____
Postcode:
If the answer is YES to any questions please give some details including dates where
possible.
Have you any history of heart trouble? (such as
heart attack, angina, valve disease, palpitations,
pains in chest, dizzy spells)
Have you any history of problems with blood
vessels? (such as thrombosis, embolus, stroke,
claudication, aneurysm, dizzy spells, blood clots)
Have you any history of chest problems?
(Bronchitis, asthma or wheezy chest)
Have you ever smoked? (if YES please state
whether you are a current or ex-smoker)
Do you suffer from diabetes?
(if YES please state if insulin dependent)
Have you any history of major illness now or in
the last 20 yrs? (such as rheumatoid arthritis,
blood disorders, cancer)
Have you any history of emotional or psychiatric
problems?
Do you suffer from osteoarthritis or rheumatoid
arthritis? (if YES please state joints affected and
indicate mild, moderate or severe and any
medication regularly taken)
Have you broken or fractured any bones? If so,
which bones and when?
Do you have any problems with your bones?
(Diagnosed osteoporosis, loss of height)
Have you any history of back problems?
This questionnaire is continued on the next page (overleaf)
Have you had any surgery on your joints?
Do you suffer from high blood pressure?
Have you had any acute illness in the last six
months? (such as influenza, recurrent sorethroat, bronchitis)
Please state any medication regularly taken for
any condition.
Have you been in hospital in the last 5 years and if
so, for how long?
Do you have any physical disabilities? (such as
visual or hearing problems)
Do you suffer from Multiple Sclerosis or
Parkinson’s Disease?
Is there any other illness or condition that affects
your general health or interferes with your
mobility?
How many times have you fallen in the past year
(approximately)?
Can you get down onto the floor and up again
unaided?
Do you use public transport easily?
Do you use a walking aid?
Approximately how tall are you and how much do
you weigh?
Black’s Score – Fracture Risk
For completion by PSI Student
What is your current age?
Less than 65
65-69 years
70-74 years
75-79 years
80-84 years
85 or over
Have you broken any bones after the Yes
age of 50 years?
No
Don’t know
Has your mother had a hip fracture
Yes
after the age of 50?
No
Don’t know
Do you weight 125 lbs or less?
Yes
125 lbs = approx 57 kg or
No
8 stone 13 lbs
Don’t know
Are you currently a smoker?
Yes
No
Do you usually need to use your arms Yes
to assist yourself in standing up from a No
chair?
Don’t know
Have you ever had a DEXA bone scan? No
Don’t know
Yes Hip Total BMD Tscore >=-1
-1 to -2
-2 to -2.5
<=2.5
Score
0
1
2
3
4
5
1
0
0
1
0
0
1
0
0
1
0
2
0
0
0
0
0
2
3
4
SHORT FES-I QUESTIONNAIRE
Introduction for PSI student to read out:
Now we would like to ask some questions about how concerned you are about the
possibility of falling. Please reply thinking about how you usually do the activity. If you
currently don’t do the activity, please answer to show whether you think you would be
concerned about falling IF you did the activity. For each of the following activities, please
tick the box which is closest to your own opinion to show how concerned you are that you
might fall if you did this activity.
Tick the relevant answer
Not at all
concerned
Somewhat
concerned
Getting Dressed
or undressed
⃝
⃝
⃝
⃝
Taking a bath or
shower
⃝
⃝
⃝
⃝
Getting in or out
of a chair
⃝
⃝
⃝
⃝
Going up or down
stairs
⃝
⃝
⃝
⃝
Reaching for
something above
your head or on
the ground
⃝
⃝
⃝
⃝
Walking up or
down a slope
⃝
⃝
⃝
⃝
⃝
⃝
⃝
⃝
Going out to a
social event (eg.
Religious service,
family gathering
or club meeting)
Fairly concerned Very concerned
CONFIDENCE IN MAINTAINING BALANCE QUESTIONNAIRE
Rate your confidence while performing the activity without assistance from another
PERSON. If a walking aid is normally used then it can be ‘used' during the activity. If you do
not do the activity, imagine how you might feel if you did do that activity.
1.
How confident are you that you can sit down in a chair without losing your balance?
Not confident
2.
Slightly Confident
Confident
Slightly Confident
Confident
Slightly Confident
Confident
Slightly Confident
Confident
How confident are you that you can go down stairs indoors, not using the handrail,
without losing your balance
Not confident
10.
Confident
How confident are you that you can walk over an uneven pavement without losing
your balance using your usual walking aid if necessary?
Not confident
9.
Slightly Confident
How confident are you that you can walk down a gentle slope using your usual walking
aid if necessary?
Not confident
8.
Confident
How confident are you that you can walk up a gentle slope indoors without losing
your balance using your usual walking aid if necessary?
Not confident
7.
Slightly Confident
How confident are you that you can walk without support for about 10 yards indoors
without losing your balance?
Not confident
6.
Confident
How confident are you that you can stand unsupported for about 5 mins without
losing your balance?
Not confident
5.
Slightly Confident
How confident are you that you can pick up something from the floor without losing
your balance - not holding on to any support?
Not confident
4.
Confident
How confident are you that you can get up out of a chair without losing your
balance?
Not confident
3
Slightly Confident
Slightly Confident
Confident
How confident are you that you can go up stairs indoors, not using the handrail,
without losing your balance
Not confident
Slightly Confident
Confident
Under each heading, please tick the ONE box that best describes your health TODAY
MOBILITY
I have no problems in walking about
I have slight problems in walking about
I have moderate problems in walking about
I have severe problems in walking about
I am unable to walk about





SELF-CARE
I have no problems washing or dressing myself
I have slight problems washing or dressing myself
I have moderate problems washing or dressing myself
I have severe problems washing or dressing myself
I am unable to wash or dress myself





USUAL ACTIVITIES (e.g. work, study, housework,
family or leisure activities)
I have no problems doing my usual activities
I have slight problems doing my usual activities
I have moderate problems doing my usual activities
I have severe problems doing my usual activities
I am unable to do my usual activities





PAIN / DISCOMFORT
I have no pain or discomfort
I have slight pain or discomfort
I have moderate pain or discomfort
I have severe pain or discomfort
I have extreme pain or discomfort





ANXIETY / DEPRESSION
I am not anxious or depressed
I am slightly anxious or depressed
I am moderately anxious or depressed
I am severely anxious or depressed
I am extremely anxious or depressed





UK (English) v.2 © 2009 EuroQol Group. EQ-5D™ is a trade mark of the EuroQol Group

We would like to know how good or bad your health is
The best health
you can imagine
TODAY.
100

This scale is numbered from 0 to 100.

100 means the best health you can imagine.
95
90
0 means the worst health you can imagine.

Mark an X on the scale to indicate how your health is TODAY.

Now, please write the number you marked on the scale in
85
80
75
the box below.
70
65
60
YOUR HEALTH TODAY =
55
50
45
40
35
30
25
20
15
10
5
0
The worst health
UK (English) v.2 © 2009 EuroQol Group. EQ-5D™ is a trade mark of the EuroQol Group
you can imagine