Consumer Held “Healthy Ageing Assessment and Management for Falls and Fracture Risk” form, please fax this page to the next
known service provider with the “Healthy Ageing Transfer of Information for Falls and Fracture Risk” form.
GP, Nurse, Allied Health, Emergency Department
Use if 2 or more Falls or Balance and Gait Difficulties or if have
Osteoporosis.
The falls and injury risk profile – Testing and referral guide.
Tested by
Date
Name
Address
Date of Birth
Phone Number
Medical diagnoses / chronic conditions
RISK
FACTOR
Injury risk Osteoporosis
Vision
Gait, balance
Medications
Falls and injury risk profile - test and criteria for
scoring
ASK – ‘Has a doctor or radiologist ever told you that you
have osteoporosis?’
TEST - Far visual acuity both eyes with corrective
spectacles,
using 3 or 6 metre Snellen chart.
Testing of each eye separately is recommended – score 1
if either eye is worse than 6/12
TEST - Timed Up and Go Test - stand up from chair (may
use arms), walk 3 m, turn around, walk back to chair, turn
and sit
down
(Podsiadlo and Richardson, 1991)
[*10-14 secs = 1 point, *more than 14 secs = 2 points]
TEST - Ability to stand up from chair without using arms patient folds arms and attempts task in less than 2
seconds
(Nevitt, 1997)
ASK -‘Has fear of falling made you avoid any (of your)
usual activities?’ (Powell and Myers, 1995)
Result and Score
(click on the box)
Click if Yes
Yes
Click if worse than 6/12
1
(6/12)
1
<10
10-14
>14
0
1
2
Click if unable
Unable
1
Click if Yes
Yes
1
ASK -‘During the past 2 months, have you had any
episodes of
feeling dizzy, unsteady, or like you were spinning or
moving, lightheaded or faint?’ If Yes, then “has this
dizziness been present for at least one month (either
intermittently or persistently)?” (Tinetti et al, 2000)
ASK -‘Do you have foot pain during walking?’ Clinical
observation of marked swelling or deformity (Menz and
Lord, 2001)
Four or more prescription medications prescribed and
taken more than three days in previous week
Click if Yes
Yes
1
Click if Yes
Yes
1
Click if more than 4 meds
(4+ meds)
1
Medications –
psychoactive
Psychoactive medications prescribed and taken more than
three days in previous week.
Click if more than 3 days
Yes
2
Low
(0 to3 points)
Medium (4 to 6 points)
High
(7 points and over)
Total score
Overall Risk
Strength, ADL
Fear of
falling
Dizziness
Foot problems
Medications –
polypharmacy
D:\116097793.doc
Consumer Held “Healthy Ageing Assessment and Management for Falls and Fracture Risk” form, please fax this page to the next
known service provider with the “Healthy Ageing Transfer of Information for Falls and Fracture Risk” form.
© The Falls and Injury Risk Profile, Michele Sutherland 2001 Permission to use this tool has been granted to the
Best Foot Forward falls prevention project by Michele Sutherland. The Suggestions and Management referral
option have been adapted from those developed by Stay On Your Feet – Adelaide West falls and injury
prevention project funded by the Commonwealth Department of Health and Ageing
See below for Suggestions for Management and Referral/liaison options
The Professional Services Directory for Falls Prevention lists where a number of these services
are available
RISK FACTORS
PRESENT
Suggestions for GP management
Injury risk Osteoporosis
Medication, diet, exercise, hip protector devices in
underwear
Vision
Eye examination
Medications
education re use of multi-focal spectacles, etc
Gait, balance
Diagnosis and management of musculoskeletal and
neurological disorders.
Gait aids
Exercise
Home aids / equipment for Activities of Daily Living (ADL)
Strength, ADL
Fear of falling
Consider psychological factors such as depression,
anxiety, medication, inactivity, sleep hygiene
Dx reversible causes, Ax of medications and hydration,
avoid medications with vestibular / hypotensive effects
Dizziness
Foot problems
Medications –
polypharmacy
Medications –
Treatment of calluses, corns, footwear modification, gait
aid, diabetes management, peripheral neuropathy screen,
anti-inflammatory drugs
Prescribe lowest effective dosages and minimize total
medications
Prescribe with caution, investigate alternative sleep
therapies
psychoactive
Referral / liaison options
Geriatrician, Dietitian
Endocrinologist
Physiotherapist
Optometrist
Opthalmologist
Occupational therapist
Low vision clinic for mobility
training and home assessment
Physiotherapist
Rehabilitation specialist
Orthopaedic surgeon
Prosthetist / Orthotist
Rheumatologist
Neurologist
Occupational therapist
Home-based or community Day
Therapy rehabilitation, exercise
group
Psychologist, Psychiatrist,
Neurologist
Home-based or community Day
Therapy rehabilitation, exercise
group
Geriatrician
Neurologist
Otolaryngologist
Physiotherapist
Cardiologist
Podiatrist
Orthopaedic surgeon
Orthotist / Bootmaker,
Physiotherapist
Pharmacist via Home Medicines
Review (DMMR)
other treating specialists
Pharmacist via Home Medicines
Review DMMR
Psychiatrist, Psychologist
Exercise group
Possible plan of action for those at differing risk levels



Low – treat and refer for presenting risk factor(s)
Medium – consider assessment and/or multidisciplinary management / MBS careplanning with Day Therapy
or Metropolitan Domiciliary Care
High - as for ‘medium’ plus consider Falls and Balance clinic and/or respite admission to RAC, or short term
to Tregenza or remain in the home with input from Metro Home Link.
D:\116097793.doc
Consumer Held “Healthy Ageing Assessment and Management for Falls and Fracture Risk” form, please fax this page to the next
known service provider with the “Healthy Ageing Transfer of Information for Falls and Fracture Risk” form.
Communication between Health Professionals
Please convey information here to other Health professionals
GP’s may consider incorporating this tool in Chronic Disease Management
Primary Coordinator of Clients Management Plan (if you are taking responsibility
for the coordination of this plan please enter your name.
DO NOT ENTER ANOTHER PARTIES NAME WITHOUT PRIOR DISCUSSION
Name:
Contact Details:
Information for GP
Information for Service Provider
Action Plan
Referrals Made
Profession
Whom
Date
Review Date
Due
D:\116097793.doc
Completed
By Whom