Section 1 – Client details

Please fill in all information so that the client can be contacted about a falls class. Thank you

Title

Forename(s)

Surname*

Address line 1

Address line 2

Town

Postcode*

Main Telephone No.*

Email address

Section 2 – Referrals for falls classes

Referrer's name*

Referrer's role/title

Referrer's address

Date of referral

Referrer's phone number

Referrer's email*

GP Name

GP surgery

Falls History - Give details about any previous falls; walking aids used; anxieties around falling; whether the client is confident outdoors.

How many falls has the client had in the last 3 months?*

Is the client anxious about falling?

Is the client confident outdoors?

Does the client use a walking aid?

Any other relevant information?

Referrer's confirmation

Patient's consent