CONCERNED ABOUT FALLS/MOBILITY?

Please answer questions below to send the referral form to your local authority. The local authority will contact you within 2 to 5 days to make an appointment.

Have you recently fallen at home? (ie, in the last 3 months)
Yes No

Where?

  • Indoors – when you get out of bed
    Yes No
  • Indoors – when you get out of a chair
    Yes No
  • Indoors – slippery/wet surfaces
    Yes No
  • Outdoors
    Yes No
  • Climbing the stairs
    Yes No
  • Steps
    Yes No
Do you have a walking aid?
Yes No
Do you live on your own?
Yes No
Do you have a carer/relative?
Yes No
Can someone reach you in an emergency?
Yes No
Do you receive any homecare?
Yes No
Are you seeing an Occupational Therapist or Another Service?
Yes No
Do you have difficulty standing up from any of the following:
  • The floor?
    Yes No
  • The toilet?
    Yes No
  • The chair?
    Yes No
  • The settee?
    Yes No
Do you have any grab rails fixed in your home?
Yes No

Where?

  • Bottom of stairs
    Yes No
  • Alongside the length of the stairs (from top to bottom)
    Yes No
  • Front door
    Yes No
  • Bathroom
    Yes No

If you do not have any grab rails fixed in your home and need them, please select the appropriate area below.


Front door


Stairs


Bathroom

 

Are you concerned about any other risks?
Yes No