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Falls Prevention Referral Form - St John staff

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REASON FOR REFERRAL: Check those that apply

Recent Fall (within last 6 months)

At risk of falling due to their strength and balance

Preventative strategy to maintain wellness

Other – please comment:

CLIENT DETAILS

Client Name:

Referral date:

NHI:

DOB:

Gender: Female Male Rather not say Gender non-binary

Ethnicity:

Address:

Home Phone:

Mobile:

Email:

Please check your email address for errors

Medical Information: (please select if any apply to this client and provide additional information if appropriate)

Diabetes

High Blood Pressure

Stroke

Stroke date

Respiratory condition:

Asthma

COPD

Heart condition:

Angina

Recent (< 6 months) heart attack

Recent (< 6 months) CABG

AF

Recent (< 6 months) knee or hip replacement)

Musculo-skeletal condition/injury

Stress/Anxiety/Depression

Reduced hearing

Reduced eyesight

Referred by (name and organisation):

Client Consent: I would like to be referred to a community strength and balance class and consent to my details and any relevant medical information being sent to Sport BOP and the relevant class instructor.

Date:

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EXCLUSION AND INCLUSION CRITERIA

Inclusion Criteria:

These classes are designed for and are suitable for:

• Any older adults (65+) who could benefit from improving their strength and balance. Note, patients under 65 years are welcome to be referred if they are at risk of falling or have a history of falls.
• Older adults with the potential and physical capability to be ambulatory even if limited initially.
• Older adults who rely on a walking aid such as a walking stick or frame.
• Older adults with very limited mobility can attend if they have someone to support them.

Exclusion criteria

These classes are not suitable for:

• Older adults needing a level of support that would disrupt the teaching of the class or who need full time care.
• Older adults with conditions that prevent them from following instructions and participating without disrupting other
• Older adults who have any of the following medical conditions: unstable angina, unstable high or low blood pressure, uncontrolled diabetes.
• Older adults who have acute medical conditions such as a recent cardiac, neurological, respiratory issue or a recent joint replacement.
• Older adults with very limited mobility and no one to support them in a class.