Fall Risk Information Form

If you have been requested by the surgery to submit information relating to any falls and associated information in order to update your records, please use this form.

We are trying to identify patients who are at risk of falls or who are already having falls and whether there is anything we can do to reduce your risk and prevent these from occurring. We would be very grateful if you could answer the following questions.

Fall Risk Information Form

Fall Risk Information Form

In the last 12 months

Have you had any falls?
Have you needed help with outside activities and with keeping house, including having difficulty with stairs and needing assistance with bathing and/or dressing?
Are you completely dependent on personal care?
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Please upload any relevant information in relation to this form.
Maximum upload size: 104.86MB