Falls Prevention Application Form printable pdf download

FALLS PREVENTION PROGRAM

Referral Form

285 Cummer Avenue, Toronto, ON M2M 2G1

Tel: 416-224-6948 | Fax: 416-226-3358

PATIENT’S NAME:

D.O.B.:

OHIP NUMBER: (Include Version Code)

YYYY

PATIENT’S ADDRESS:

PHONE #:

CAREGIVER NAME/CONTACT INFO:

LANGUAGES:

MALE

REQUIRES INTERPRETER:

YES

FEMALE

________________________________________________________________

CURRENT PRIMARY DIAGNOSIS:

______________________________________________________________________

DATE OF SURGERY/TYPE:

MEDICAL HISTORY:

Hypertension

Stroke: Type: ________________

History of Falls

Pacemaker

Seizures

Osteoporosis

Vascular Disease

Diabetes:

Type 1;

Type 2

Fractures: ___________________

Other Cardiac: _______________

Cancer: Type: ________________

Arthritis: Type:_______________

Other: ____________________________________________________________________________________

(MRSA, VRE, etc.):

Yes

No, Organism/Location: _____________________

ISOLATION REQUIREMENTS

_____________________________________

medical or psychiatric instability, cognitive impairment, complex needs requiring active

CONTRAINDICATIONS:

in-home or inpatient services, lives > 1 hour drive from the hospital

REASON FOR REFERRAL & SERVICES REQUIRED:

Please specify the patient issues (as many as relevant) that require the following services:

Recent falls

Dizziness and/or fainting spells

Decreased mobility

Taking > 4 prescribed medications

Taking ≥ 1 high risk medications for falls

Poor balance

(e.g. benzodiazepines, opioids, psychotropics, anticholinergics, diuretics, etc.)

Leg weakness

Difficulty managing self-care

Other issue(s): _______________________________

Poor vision

___________________________________________

Interprofessional Assessment Includes:

•

Assessment by an Occupational Therapist and a Pharmacist at patient’s residence

•

Physiotherapy Assessment for participation in a group exercise program at St. John’s Rehab

•

Group Education Session on site by a Physiotherapist and Dietitian

•

Social Worker Assessment

REFERRING PHYSICIAN’S NAME/SIGNATURE:

REFERRING PHYSICIAN’S PHONE #:

FAX #:

REFERRING FACILITY:

DATE OF REFERRAL: ____________________________

Please refer to Falls Prevention Program brochure or website for inclusion/exclusion criteria and other information

/falls

Falls Prevention Application Form

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