Falls Assessment and Education Service Referral Form > Gloucestershire Health and Care NHS Foundation Trust

Patient details

Name *

Address *

Street Address Address Line 2 City County Post code

Telephone Number *

Date of Birth *

Gender *

NHS No

GP Name

GP Surgery name and address *

GP Telephone Number

Communication Requirements

Do you need any additional help with reading/listening/speaking?

Please detail help required

E.g. translator or a hearing loop

Falls History

Number of falls in the past 6 months? (this is to make sure you are contacted by the correct team) *

Please describe your last fall *

Where you were, what time of day, what happened? Please include details of any dizziness or light-headedness experienced, any loss of consciousness or injuries sustained

Your Mobility

Do you have any problems with balance?

Do you have difficulty getting up from a chair?

Do you have difficulty getting off the floor?

Do you use anything to help you walk?

If you do use anything to help you walk, please tell us what you use

Do you live alone?

Please tell us who you live with

Have you had previous input regarding falls? If so, when and by whom?

For example, home assessment by occupational therapist or Active Balance classes, etc.

Do you currently have any other services involved?

E.g. community nurses, frailty team, etc

Appointment Details

Please indicate which hospital you would like to attend for your appointment *

If you are unable to attend any of the hospital locations, please tell us why.

You will be contacted to discuss the referral. If you would prefer us to speak to someone else, please tell us who would be the best person to contact and their telephone number

Referrer details

Referrer name

Relationship to patient

Telephone number

Place of work

If a staff member is making the referral

Covid 19 Information