Falls prevention exercise service

Referral for participation

Client details:

Title / First Name / Surname
Address
Post Code / Client Tel. :
Date of Birth: /  NHS number:
Next of kin/carer / Relationship: / Telephone:
Does the patient have a learning disability? Yes No
Need transport to get to exercise session? Yes No
Client’s GP / Initial / Surname

GP Practice

Referrer details: / First Name / Surname
Profession

Referrer address:

Reason for referral: / Referrer Tel.:
Referrer’s signature: ………………………………………….. / Date: …………………………
? Appropriate referral. Check listPlease tick () relevant boxes

History of falls&/orunconfident/problems with balance YES

Mobile (with walking aid if needed, but no human assistance) YES Able to get out of a low chair/up from the toilet without assistance (but may have difficulty)

No Health Contra-indications(see contra-indications detailed below)

 Unstable angina or uncontrolled heart disease;  Tachycardia or uncontrolled arrhythmia;

 Resting systolic BP > 200mmHg or Diastolic BP > 110mmHg;  Severe Parkinson’s disease;

 Severe breathlessness or dizziness;  Unmanaged pain;  Acute systemic illness

 Functional limiting diseases, such as severe stroke; Severe cognitive impairment (unable to follow simple instructions) NONE

Motivation to attend: please tick () one of four boxes below

No interest/sceptical
/ Uncertain/needs encouragement / Interested / Very interested

Inappropriate referral

/

Discuss with service

/

Refer

/

Refer

If inappropriate please refer Clients to their GP.

NAMENHS Number

PHYSICAL CONDITION OF CLIENT

Information provided will enable the Falls Exercise Instructor to adapt exercise safely & effectively

Patient has/susceptible to: - Please tick () all relevant boxes

Impaired balance Irregular heartbeat (Arrhythmia)Impaired alertness

OsteoporosisAngina Visual impairment

Arthritis (OA)Asthma/COPD Hearing impairment

** OTHER

** Current Medication(s)

Other precautions or special considerations

Specific exercises/approaches to be included (if known)

History of falls & fractures Please tick () all relevant boxes

No. recorded falls in last 12 months ……… Needed help to get up from floor after a fall? Y N

Fear of falling? Y N

Previous fractures Y N Wrist? Hip? Spine? other? (specify) ……………..

Mobility & living arrangements

 Walks outdoors? Y N  Transfers independently? Y N

 Lives alone? Y N  Which floor? ……………………  Uses stairs? Y N

 Walking aid? Y N If Yes, use of Stick Frame Wheelchair

Categories for exercise classPlease tick ()

High – Independently active without aid indoors, May use stick outdoors.

Intermediate – Use stick or maybe furniture indoors

Low – Can sit to stand but maybe effortful, Use sticks or frame indoors

If needs help to stand or supervision to walk. Refer instead to Appropriate Therapy Team

Therapists please complete outcome measures below

TUAG………. Secs (if possible) Turn 180…….. Steps VAS /10 (Fear of Falling)

0 No fear 10 Terrified

Please refer by telephone: 0208 661 3908

IMPORTANT Fax referral sheets to 0208 661 3910 or email to:

**GP’s: Mayfax EMISPatient Summary

Revision:October 2016