Referring Doctor:  <<Doctor:Name>>	
Provider No:  <<Doctor:Provider Number>>	
Address:  <<Doctor:Full Address>> 	
Phone: <<Practice:Phone>>Fax:  <<Practice:Fax>>	

The MDT Falls Management Clinic has been established to provide a timely, evidence based approach to assessing and managing those community dwelling people that are falling or at high risk of falling.  Clients attending the clinic will be assessed by Occupational Therapy and Physiotherapy and findings, recommendations and interventions will be communicated back to you by way of a goals of care plan or discharge summary.

The following information is important for the MDT Falls Management Team to triage the referral and address your patients’ needs in an appropriate way.

Patient Name:  <<Patient Demographics:First Name>>  DOB: <<Patient Demographics:DOB>>	
Address:  <<Patient Demographics:Full Address>>	
Phone:  <<Patient Demographics:Phone (Home)>>  Mobile: <<Patient Demographics:Phone (Mobile)>>	
Medicare:  <<Patient Demographics:Medicare Number>>  Concession: <<Patient Demographics:Pension Number>>	

Clinical Reason for Referral: <<Clinical Reason for Referral>>	

Relevant Intercurrent Medical Conditions or information: <<Relevant Intercurrent Medical Cond or Information:>>	

Current Medications:
Note: Poly pharmacy and certain families of drugs such as but not limited to antipsychotics, antidepressants and benzodiazepines are consistently associated with a higher falls risk (Park et al. 2015; Richardson, Bennett & Kenny 2015; Seppala et al. 2018)
<<Clinical Details:Medication List>>	

Falls Risk FROP-Com Screen
	Score	
FALLS HISTORY		
1.	Number of falls in the past 12 months?
Impaired balance and gait and previous falls are risk factors for falls in the future (Ambrose, Paul & Haursdorf 2013).	<<Number of falls in the past 12 months?>>	
FUNCTION: ADL STATUS		
2.	Prior to this fall how assistance was the individual requiring for instrumental activities of daily living (eg cooking, housework, laundry)?
If no fall in past 12 months rate current function.	<<Prior to this fall how much assistance required>>	
BALANCE		
3.	When walking and turning does the person appear unsteady or at risk of losing their balance?
Observe the person standing, walking a few metres, turning and sitting.  If the person uses an aid observe the person with the aid.  Do not base on self report.
If level fluctuates, tick the most unsteady rating.  If the person is unable to walk due to injury, score 3.	
<<Does pt appear unsteady/at risk of losing balance?>>

0-3 Low risk  4-9 High risk 	TOTAL RISK SCORE = <<Total Risk Score>>	

Sincerely

<<Doctor:Name>>	<<Miscellaneous:Date>>