Self Referral Form - Falls & Bone Health Service

Falls & Bone Health Service Self Referral Form
DISCLAIMER

Please note that we are using Jotform as part of our referral process. Further information can be found on our website. https://www.hrch.nhs.uk/download_file/view/842/377

Please Read This Before Continuing

We are a preventative service. This self-referral is for patients who are needing a Falls risk assessment to understand how to reduce their risk of falls and receive advice and mitigation of these risks. It is not appropriate if your needs are urgent, eg you are currently on the floor, or have fallen recently with a new injury requiring rehabilitation or an urgent walking aid assessment. In this instance, please call 111 or get advice from your GP on which team may help you best.

The Referrer must gain consent of service user or person acting on their behalf.

Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
NHS Number*
Email
example@example.com
Mobile Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Registered GP*
If Other, Mention your GP Practice
Referral Date*

MonthDayYear
Date
Referral Received From *
Ethnicity
Reason for referral: Please give some indication why you are requesting a Falls risk assessment by the Falls & Bone Health Service? Include a BRIEF summary of the problem
Have you received an assessment from our service in the past?
Are you currently receiving treatment from any other service provider at HRCH trust?

NoYes - Richmond Response and Rehabilitation TeamYes - Musculoskeletal Physio serviceYes - Occupational Therapy
Are you a Richmond Resident?

Eligibility – Are you currently independently mobile with or without a walking aid? (i.e, need no external support to mobilise)
How many falls have there been in the past year?
How often are “near miss” falls occurring?
Has the normal functional level deteriorated as a result of the fall or other issue?
Are there any concerns regarding the safety of their environment? e.g – equipment, stairs, access, garden
If 'Yes', please give details*
Are they awaiting investigation for a suspected condition, or have a known condition? – e.g cardiac, neuro such as stroke or parkinsons?
If 'Yes', please give details*

DECLARATION OF CONSENT
Name: of Service user/ legal guardian/ lasting power of attorney:

First NameLast Name
I, consent to receiving e-mail correspondence and text alerts from the Falls prevention service regarding appointment information and general information regarding the service.
Email

YesNo
Text

YesNo
Name in captials

First NameLast Name
Relationship to the service user
Should be Empty:

Falls & Bone Health Service Self Referral Form