FALLS MEDICAL SPECIALIST ASSESSMENT PERSONAL DETAILS
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1 FALLS MEDICAL SPECIALIST ASSESSMENT PERSONAL DETAILS Title: Forename: Surname:. Address:... Town: County: Postcode:... Telephone: DoB:.... Doctor s Name:.. Address:.. Postcode:... Telephone: Fax:... Consent Given: Yes/No Hospital No:. NHS No:.. Ethnicity: Caucasian Afro Caribbean Asian Indo Asian Chinese Other Marital Status: Married/live with partner Widow Single Divorced Gender: Male Female REFERRAL DETAILS From: GP Healthcare professionals Other Reason: Frequent Faller Unexplained falls Blackouts Injurious falls from A&E Outcome: Invited to clinic Inappropriate referral DNA Date of appointment:... LIFESTYLE Height (metres):.... Weight (Kg):... BMI: Smoking Status: Non Previous Current, No. per day:... Exercise Activity: Aerobic Walks for exercise None House bound Functional activity in house Functional activity in and around house Unknown
2 Mobility: Uses walking aid Independent Uses wheelchair House bound Bed bound Unknown Diet: Low calcium Low fat Diabetic No special diet Unknown Alcohol units per week: None 1 6 units 7 14 units units units Over 35 Unknown SOCIAL CIRCUMSTANCES Lives in: Own home Residential care home Nursing care home Prison Not specified Unknown Lives with: Spouse Relatives Carers Others Not specified Unknown Social support: Self care Social services Meals on wheels Respite care Relatives care District Nurse Private help Unknown Other Home-assessment: Adequate for needs Satisfactory Needs improvement Unsatisfactory Unknown Alarms: No alarms present Links to relatives Personal Alarm Able to call for help Unable to call for help Unknown MEDICAL CONDITIONS History: Asthma Arthritis Cancer Cerebrovascular accident Chronic depression Chronic ischemic heart disease Chronic obstructive lung disease Chronic osteoarthritis Cognitive impairment Congestive heart failure Dementia Diabetes mellitus Disease of prostate Essential hypertension Hyperthyroidism Incontinence Mild cognitive disorder Osteoporosis Parkinson s disease Peptic ulcer Peripheral vascular disease Rheumatoid Arthritis Visual impairment
3 MEDICATIONS Culprit Medications for Falling: Anticonvulsants Antidepressants Benzodiazepine Cardiac drugs Diuretics Neuroleptics Opiates Parkinson s Medication Psychotropics Medications currently taken: Medications previously taken: ALLERGIES None known Known allergies: CUSTOM QUESTIONS No of falls in last year: Date of last fall:.. Falls history: Unexplained recurrent falls Recurrent falls Unknown Falls history from: Patient Carer Family member Other Time on floor: 5 mins or less 6 20 mins 1 hr or less 2 hours or less 2 6 hours 6 to 24 hours
4 Recollection of fall: Yes No Location of fall: Indoors Outdoors Other Witness to fall: Yes No Able to get up: Yes No Factors contributing to fall: Slip Trip Medications Dizziness Palpitations Alcohol Fainting Fear of Falling: Yes No Footwear Environmental home hazards Environmental external hazards Injuries sustained: Collapse Faint Head Injury Senility Soft Tissue Injury State injuries sustained: Fragility Fracture History: Hip Humerus Pelvis Vertebrae Wrist Other, please state:.... Circumstances surrounding fall: EXAMINATIONS CARDIOVASCULAR EXAMINATION Enquiry: Chest pain Palpitations SOA PND Orthopnoea Pallor Chubbing Jaundice Cyanosis Tachycardia Bradycardia Pulse Rate: Increase Decrease Normal PR Rhythm: Regular Irregular Regular irregular Irregular irregular PR Character: Weak Strong JVP: Normal Raised Decreased Heart Sounds: Normal Abnormal Murmur Carotid Bruits: Yes No Oedema: Yes No Comments:
5 RESPIRATORY EXAMINATION Enquiry: SOB Cough Wheeze Phlegm Haemoptysis Chest Wall: Deformity Normal Trachea: Problem Normal Percussion of Chest: Normal Abnormal Breath Sounds: Normal Abnormal Rate: Normal Abnormal Added Sounds: ABDOMINAL EXAMINATION GI Enquiry: Abdo.pain Nausea PR Blood Weight loss Altered bowel habit GU Enquiry: Dysuria Frequency Nocturia Incontinence Haematuria Catheter Tenderness: Tenderness Pain and tenderness Masses: Present Absent Hepatomegaly: Present Absent Splenomegaly: Present Absent Palpable Kidney: Present Absent Other Masses: Present Absent Aortic Aneurysm: Present Absent Bowel Sounds: Normal Abnormal PR: Normal Abnormal Comments: NERVOUS SYSTEM EXAMINATION System: Blackouts Fits Numbness Weakness Headaches Cranial Nerves Normal: Yes No Cataracts: Yes No Fundoscopy: Diabetic retinopathy Hypertensive Glaucoma Unable to visualise Normal Parkinsonism: Present Absent Cerebellar Signs: Present Absent Nystagmus: Yes No
6 Finger Nose: Normal Abnormal Dysdiadochokinesis: Normal Abnormal Heel Shin: Normal Abnormal Romberg s: Present Absent VISUAL ACUITY EXAMINATION Right Eye Left Eye PNS EXAMINATIONS REFLEXES: Area Right Left Biceps Triceps Supinator Knee Ankle Plantars TONE: Right Arm Left Arm Increase Decreased Normal Increase Decreased Normal Right Leg Left Leg Increase Decreased Normal Increase Decreased Normal POWER: Right Arm Left Arm Grade: Grade: Right Leg Left Leg Grade: Grade:
7 RANGE OF MOVEMENT: Arms o Movement Legs o Movement Area R L Area R L Shoulder abduction Shoulder adduction Elbow flexion Elbow extension Wrist flexion Wrist extension Finger abduction Finger adduction Opposition Hip flexors Hip extensors Knee flexion Knee extension Ankle dorsiflexion Ankle plantiflexion JOINT DEFORMATIES: System: Stiff joints Joint swelling Painful joints Hands: Yes No Elbows: Yes No Shoulders: Yes No Spine: Yes No Hips Knees: Yes No Ankles: Yes No SENSATION: Intact: Yes No Proprioception intact: Yes No Vibration intact: Yes No OTHER EXAMINATIONS: Gait assessment: Stable Unstable Unknown Gait Comments: Balance: Good Poor Balance Comments: Walking Aids: Stick Frame Other None
8 Footwear assessment: Appropriate Inappropriate Unknown Foot Examination: Oedema Colour Major deformities Lower Limb Examination: Upper Limb Examination: Walking Aids Assessment: Able to use appropriately Unable to use appropriately Unsuitable for needs Visual Assessment: Normal Mild impairment Moderate impairment Severe impairment Unknown Hearing: Normal Mild impairment Moderate impairment Severe impairment Unknown Physical Signs: Pulse rate Pulse regular Pulse irregular BM Temp Blood Pressure lying systolic... Blood Pressure lying diastolic. Blood Pressure Standing systolic. Blood Pressure Standing diastolic TESTS Test Test Score Test Result Recommended Action 6CIT 4 Item GDs Bartel ADL Falls Risk Fracture Risk Must Tool Home Assessment Elderly Mobility Score
9 MMSE Timed get up and go INVESTIGATIONS Blood Count: Normal Abnormal Blood Glucose: Normal Abnormal ECG: Normal Abnormal EEG: Normal Abnormal ESR: Normal Abnormal Hearing Test: Normal Abnormal Liver Function: Normal Abnormal Serum vitamin B12 measurement: Standard chest X-ray: Normal Abnormal Normal Abnormal Thyroid Function: Normal Abnormal Urea and Electrolytes: Normal Abnormal Vitamin D measurement: Normal Abnormal
10 OVERVIEW Falls intervention required: No intervention Diagnosis & Treatment of underlying medical problem Intervention for cardiac syncope Full dose Calcium & Vitamin D Medication review Balance and gate training Strengthening training Footwear advice Vision advice and follow up Falls interventions made: Physiotherapist Occupational therapy Podiatry Ophthalmologist Psychologist Social services Strength and balance training Syncope services Foot advice and follow up OT Referral Rehabilitation, eg OT and/or PT referral Getting up strategies Home hazard modification Safety and/or mobility equipment Repairs and/or improvements Social care support Psychological support Cardiologist Respiratory Services Medications review Smoking preventions Service for reduction in alcohol consumption Day hospital services Community rehabilitation services Exercise programme AUDIT INFORMATION Time scales: From.. To:... Number of patients Age Group Gender Reason for referral Problems identified/risk factors/diagnosis Interpretations Recommendations made
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