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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