Care & Cure

(Centre for Child Development & Rehabilitation)

19, Radhe Pushp Bhawan, Opposite Aamra Shree Marriage Garden,
Nayapura, kolar Road, Bhopal, Madhya Pradesh. Pin – 462042
0755 – 4255553, 9425405490 / 9425818908

FULL FALLS SPECIALIST PHYSIOTHERAPY ASSESSMENT

To be completed by a physiotherapist
(if unable to carry out PPA and General Assessment Form not completed)
Date of assessment Name Date of Birth

Past Medical History

Drug History
On 4 or more prescription only drugs
On any of the following medication: Refer to doctor for
Sleeping tablet Water tablet Heart tablet medication
Anti-depressant Blood pressure tablet Major tranquilisers review if
List medications and dosages: this has not
been done
in last 12
months

Bone Health
Previous fragility fracture: Hip Wrist Vertebrae
Corticosteroids Rheumatoid arthritis Refer to doctor if
Alcohol/smoking Parental history osteoporosis/hip fracture
osteoporosis risk
Already on bone health treatment. How long: and unmanaged
Height (cm): Weight (kg): FRAX score:

Social History

Falls History
Number of falls in last 12 months:
Location of fall(s):

Cause of fall(s)/mechanism:

Injuries:
 Care & Cure
(Centre for Child Development & Rehabilitation)
19, Radhe Pushp Bhawan, Opposite Aamra Shree Marriage Garden,
Nayapura, kolar Road, Bhopal, Madhya Pradesh. Pin – 462042
0755 – 4255553, 9425405490 / 9425818908

Was the person able to get up from the floor? Yes No

Was the person able to summon help following the fall? Yes No
Does the person have a pendant alarm? Yes No
Fear of falling or restricting any activities they appear capable of doing: Yes No
Details:

Name: DOB:
Functional Ability
Transfers:

ADLs:

Any equipment in situ:

Gait and Balance Analysis (Including aid used)

Walking aid provided Type:

Timed Up and Go Test
Under 15 seconds 15 seconds or over
→ Consider leisure services → Full physiotherapy assessment required
Outcome measures (if not measured using PPA)
Near tandem TUSS (if near 180° Turn Alternate step test Sit to stand test
stand (time able to tandem stand (time taken for 8 (time taken to STS
perform test with under 10 seconds) alternate steps) 5 times with arms
eyes closed) crossed)

Strength and Strength and Strength and Strength and

If under 10 seconds balance training if balance training if balance training if balance training if
complete TUSS under 60 seconds over 5 steps over 10 seconds over 12 seconds

Sensation/Reflexes/Proprioception/Co-ordination
Sensation Proprioception

Reflexes Co-ordination

Feet and Footwear

 Care & Cure
(Centre for Child Development & Rehabilitation)
19, Radhe Pushp Bhawan, Opposite Aamra Shree Marriage Garden,
Nayapura, kolar Road, Bhopal, Madhya Pradesh. Pin – 462042
0755 – 4255553, 9425405490 / 9425818908

Any foot problems i.e. corns, bunions, swelling, overgrown toenails: If needed:
Referral to podiatry
Referral to orthotist
Inappropriate, poorly fitting or worn footwear:
Advice on footwear
Other:
Continence
Urinary: Urgency Nocturia Stress Refer to Continence
Bowels: Service/doctor/DN
Incontinent of faeces Constipation
ROM/strength/function

ROM Strength

Left Right Left Right

Upper limb

Lower limb

Trunk

Comments:
 Care & Cure
(Centre for Child Development & Rehabilitation)
19, Radhe Pushp Bhawan, Opposite Aamra Shree Marriage Garden,
Nayapura, kolar Road, Bhopal, Madhya Pradesh. Pin – 462042
0755 – 4255553, 9425405490 / 9425818908

Nutrition
Unexplained weight loss Poor appetite Refer to doctor
Cognition
Lacks insight into general safety/unconcerned re falls
Refer to doctor
Difficulty following instructions and/or confusion
Mental Test Score Total: /10 < 8 = Dr
Age Time to the Recall Year Location
nearest hour ‘42 West
Street’
Recognition of Year of 2nd DOB Current Count from
two people World War monarch 20-1
(1939-1945)
Bowels: Incontinent of faeces Constipation

Name: DOB:
Intervention
No intervention required Otago home exercise programme
Refer to falls clinic (Comprehensive Community exercise class
multidisciplinary falls assessment) Strength & balance class at
Refer to Osteoporosis Clinic (Guy’s or KCH) Guy’s/WC/LCCC/Dulwich
Refer to Continence Clinic One-to-one physiotherapy
Refer to CGA Clinic Exercise in leisure centre
Refer to Vestibular Clinic Exercise in day centre
Refer to OT Exercise in care home
Refer to Podiatry/Orthotist Advice (please state)
Refer to GP
Refer to DN
Other (please state):
Dealing with a long lie
Fear of falling management
Name of therapist: Signed: Date:

Use to determine most appropriate of

SLIPS Segmentation exercise intervention
 Care & Cure
(Centre for Child Development & Rehabilitation)
19, Radhe Pushp Bhawan, Opposite Aamra Shree Marriage Garden,
Nayapura, kolar Road, Bhopal, Madhya Pradesh. Pin – 462042
0755 – 4255553, 9425405490 / 9425818908

No/mild balance Moderate balance Severe balance impairment

impairment impairment
Marked falls risk score on
Low/no/mild falls risk score Moderate/marked falls risk PPA but balance is
on PPA score on PPA but balance is inadequate for safe
adequate for safe independent exercise
independent exercise
(unable to stand unsupported
(able to stand unsupported with eyes open for 30
with eyes open for 30 seconds)
seconds)

Able to participate Leisure card for general Otago home exercise One-to-one strength and
independently exercise. programme. balance training with
Walking groups. Community exercise groups. physiotherapist/assistant.
(Good cognition/ Advice on exercise.
motivation) 2A
1A 3A

Unable to participate
independently Exercise groups in Strength and balance class. One-to-one strength and
community including chronic Exercise in care homes/day balance training with
(Poor cognition/ disease exercise groups. centres. physiotherapist/assistant.
motivation/
extreme fear of falling) 1B 2B
3B