OnLineAssess

Level One Falls Risk Assessment Form - Self Assessment

Please fill in the form below. When it is complete click the submit button. N.B. You must answer the question on GP consent - we will not contact your GP if you do not wish us to.

Do you, or have you had a diagnosis of:

Do you have problems with your.....

A Lifeline is the pendant or wrist button that you carry around at home to summon help if you get into difficulty.

Title (Mr, Mrs, etc)

Full Name

Address/Postcode

Telephone

Email address

Date of Birth

Ethnicity/Nationality

Do you live alone? (Yes/No)

Do you have Lifeline in your home? (Yes/No)

Who is your GP?

Have you attended a Falls Clinic? If so when and where?

How many slip, trips or falls have you had in the last year?

Do you have problems getting up from a chair? (Yes/No) (Yes/No)

Parkinsons Disease

Diabetes

Stroke

Dementia

Are you finding it harder to get around? (Yes/No)

May we contact your GP with this information (Yes/No)

Date:

Eyesight

Hearing

Balance

Feet

When was your last eye test? (Months ago)

When did you last have your hearing checked? (Months ago)

When did you last have your feet checked? (Months ago)

Do you take 4, or more, different medicines a day? (Yes/No)