Age UK OxfordshireGeneration Games Falls Prevention Exercise Programme

Name of referrer:
Designation of referrer:
Contact details:

This service is for patientswho want to take part in a specific exercise programme to prevent falls.
It offers evidence-based strength and balance exercises, led by specialist qualified and experienced exercise teachers.

This referral form is for patients who are at risk of falling, are concerned about falls or have lost confidence in their balance.

Contact Details for the service:
Postal Address / 9 Napier Court, Barton Lane, Abingdon, Oxon OX14 3YT
Telephone / 01235 849403
Email Address /
Office Hours / Monday to Friday 9.00am - 5.00pm
Patient’s details / Patient’s background and culture
Forename / Given Name / Ethnicity / Ethnic Origin
Surname / Surname / 1st Language / Main Language
Known as / Calling Name / Interpreter required? / Y N
DOB / Date of Birth / Age / Age
Sex / Gender(full) / GP details
Title / Title / GP Name
Address & Postcode / Home Full Address (single line) / GP Address / Organisation Name
Organisation Full Address (single line)
GP Tel No / Organisation Telephone Number
NHS No / NHS Number
Hospital No / Hospital Number
Home Tel / Patient Home Telephone / Referral Date / Short date letter merged
Work Tel / Patient Work Telephone / Date sent
Mobile Tel / Patient Mobile Telephone
Email / Patient E-mail Address
Patient’s preferred contact number / Home / Work / Mobile
Patient agrees to telephone message being left? / Yes / No
Exclusion criteria
My patient does not have:
Unstable angina or uncontrolled heart disease / Severe breathlessness or dizziness
Tachycardia or uncontrolled arrhythmia / Unmanaged pain
Uncontrolled hypertension / Acute systemic illness (e.g. cancers?)

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Appropriate Referral criteria
Please tick all that apply
The patient … / is at risk of falls
is concerned about balance
has lost confidence
has had one or more non-injurious falls in the last 12 months
Other / Please specify:
The exercise programme has been discussed with the patient and they are motivated to attend
Narrative of referral letter / additional information:
(please highlight any significant comorbidities and relevant investigations)
Please tick here if you are sending any additional documents.
The referral narrative should be typed below, not in a separate letter

Medication

Allergies

Problems

Please send this referral form to

We will telephone your patient within 5 working days of receiving the form.

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