Self-Referral Form for MIS Falls Clinic SHC MIS referral form Note: Questions marked by * are mandatory Have you been seen in the past 12 months by the MIS Falls Prevention service? (Please note, if you have been assessed by the Falls prevention team within the last 12 months and there have been no significant changes in your condition, your referral will not be accepted). Yes No *This is a mandatory field. What is your NHS number Title *This is a mandatory field. First name *This is a mandatory field. Family/Surname Preferred name *This is a mandatory field. Date of birth DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Gender Male Female Transgender Rather not say Ethnicity I do not wish to disclose this White - British White - Irish Any other white background Black or Black British - Caribbean Black or Black British - African Any other black background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Any other Asian background Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Any other mixed background Chinese Any other ethnic group Religion Atheism Buddhism Christianity Hinduism Islam Jainism Sikhism Other I do not wish to disclose Preferred language/Main language spoken Yes No Will you require an interpreter? Do you have any other communication needs? Please specify Permanent address *This is a mandatory field. Home telephone number Mobile phone number Current address (if different from above) Do you live alone? Yes No If no, who do you live with? *This is a mandatory field. Are you able to attend clinic? Yes No If yes, how would you get to your appointment? Please note, transportation is not provided by the service to attend your appointment Public transport Driving self Driven by family/friend Dial-a-ride Other Reasons for referral to Falls Clinic *This is a mandatory field. Please provide a detailed description including onset of the problem *This is a mandatory field. How many falls have you had in the past 12 months? *This is a mandatory field. How often are you falling and where? *This is a mandatory field. Are you concerned about falling? (please score yourself out of 10 with 0 = not concerned and 10 = extremely concerned) *This is a mandatory field. If you have not had any falls yet but are worried about falling, please select all of the following issues which are affecting you Balance Pain Hazards in your home environment Muscle weakness Poor sensation Visual/ hearing problems Other reason Have you recently undergone a surgical procedure? Yes No Please specify Please let us know what matters most to you at the moment so we can do our best to support you (eg Tell me what is wrong, I want to be confident in going out, I want to feel safe when I am walking, I need further investigation) (Please note if you are seeking further investigation for a medical condition, please make an appointment with your GP in the first instance so that you could be referred to the most appropriate service). Past medical history Please tell us about any other medical conditions affecting you that you know about. Please tell us about the medication you are taking (including over-the-counter medication). Please can you tell us about your current level of function. How do you get around? ( Select all that apply) Independent Walking stick Wheel frame Hoist Wheelchair Are you independent with Personal Activities of Daily Living (PADL)? eg washing, dressing Yes No Do you have a package of care? None Once a day Twice a day Three times a day Other Do you have any other equipment at home to help with your function? Yes No Please specify Do you attend other social activities eg day centres, clubs Yes No Please specify Person completing this form if not the patient Name Telephone Email Please specify.
