Fall Referral

Resident Information

Name

Date of Birth or Age

Gender

Male
Female

Date of Incident

Time

Address

City

State

Zip

Phone

Incident Information

Fall Type (Select all that apply)

Fall
Slip/Trip/Stumble
Syncope
Near Syncope
Found on Floor
Other (please explain below)

Other Fall Type:

Suspected Contributing Factor (Select all that apply)

Environmental Hazard
Balance Impairment / Generalized Weakness
Orthostatic hypotension / Blood pressure changes
Medication side effects
Polypharmacy
Blood glucose abnormality
Cardiac condition / Arrhythmia
Neurological or cognitive impairment
Gait or mobility impairment
Distracted movement / Multitasking
Alcohol or substance use
Unknown
Other (please explain below)

Other Suspected Contributing Factor

Incident Environment

Location of Incident

Bedroom
Bathroom
Hallway
Kitchen
Dining Room
Living Room
Laundry Room
Stairs/Steps
Garage
Outside
Other (Please explain below)

Other Location

Environmental Hazards Present (Select all that apply)

Clutter
Loose Rug
Lack of Handrail / Grab Bar
Flooring Transition
Uneven Surface
Wet Surface
Poor Lighting
Electrical Cords
Pet
Step Stool
Footwear
None Observed
Other (Please explain below)

Other Environmental Hazards Present

Additional Notes

Authorization for Release of Information

I, the undersigned, authorize this Fire/EMS Department to release the information contained in this referral to the Senior Falls Prevention Coalition of Clay and Platte Counties for the purpose of coordinating fall prevention services, resources, and follow-up contact.

Resident / Representative Signature

Referring Agency

Department

Referral Completed By

Date

Programs & Services

Health and Wellness

Senior Resources