Get the free Falls Prevention Referral Form - benningtonrescueorg

Falls Prevention Referral Form Participant: DOB: Address: Referred to: Phone: Email: Phone: Email: Address: CDC STEADY Falls Risk Questions 1. Have you fallen in the past year? 2. Do you feel unsteady

How to fill out falls prevention referral form

How to fill out falls prevention referral form:

1. Obtain the falls prevention referral form from the appropriate healthcare provider or organization.
2. Begin by filling out the patient's personal information, including their full name, date of birth, address, and contact information.
3. Provide the patient's medical history, including any relevant conditions or diagnoses that may contribute to their risk of falling.
4. Indicate any current medications that the patient is taking, as certain medications may increase the risk of falls.
5. Document any previous falls the patient has experienced, including the date, location, and circumstances surrounding the fall.
6. Include information about the patient's living situation and any potential hazards in their home that may increase the risk of falls.
7. If the falls prevention referral form includes a section for healthcare professional assessment, make sure to have the appropriate healthcare provider complete this section.
8. Once all relevant sections of the form are complete, review it for accuracy and ensure that all required fields have been filled out.
9. Submit the falls prevention referral form to the designated healthcare provider or organization as instructed.

Who needs falls prevention referral form:

1. Any individual who has experienced a fall or is at risk of falling may require a falls prevention referral form.
2. The form may be necessary for older adults, as they are more prone to falls due to factors such as muscle weakness, balance issues, and chronic health conditions.
3. Individuals with specific medical conditions that increase the risk of falls, such as Parkinson's disease, osteoporosis, or stroke, may also need to fill out a falls prevention referral form.
4. Other individuals who may require the form include those with mobility impairments, individuals on certain medications, and those with environmental factors in their home or work settings that predispose them to falls.

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What is falls prevention referral form?

The falls prevention referral form is a document used to refer individuals who are at risk of falling to appropriate interventions and services.

Who is required to file falls prevention referral form?

Healthcare professionals, caregivers, or individuals themselves can file a falls prevention referral form.

How to fill out falls prevention referral form?

The falls prevention referral form can be filled out by providing the necessary information about the individual's fall risk, medical history, and any current interventions.

What is the purpose of falls prevention referral form?

The purpose of the falls prevention referral form is to promote early intervention and reduce the risk of falls for individuals at risk.

What information must be reported on falls prevention referral form?

The falls prevention referral form typically includes information about the individual's medical history, current medications, mobility limitations, and previous falls.