Post Fall Assessment

Have you had any falls within that 6 months? *
Fall within last 3 months *
Where did the fall occur? *
Do you require the use of an assistive device? *
Type *
At the time of the fall, where you using your assistive device? *

Action Taken Following the Fall *
Did or are you having any of the following symptoms as a result of the fall? *
Result of fall: *
Visual Impairments *
Type of Corrective Lenses *
Deficits and/or Intrinsic Contributing Factors: *
Balance & Gait Details *
Medication Details - Use of: *
A.M./P.M. *
Cognitive deficits present: *
Cardiovascular *
Incontinence *
Extrinsic Factors Potentially Related to Fall *
I have provided the following interventions to minimize/avoid fall risks *
I have assessed the above patient and made the following recommendation *