Falls risk for older people (community setting FROP-Com assessment)

Patient details

First name * Personal code * Age *

Last name * Date of birth *

Date of assessment * Marital status *

English is first language? *

Has functional english *

Falls History

Number of falls in the last 12 months? *

Injury sustained in last 12 months? *

Time of fall * Location of fall *

Direction of fall *

Cause of fall *

Injuries *

Medications & medical conditions

List all the medical conditions of the patient

Number of prescription medications *

Listed medication *

Medical conditions *

Sensory Loss

Vision deficit *

Somato deficit *

Feet & Footwear

Foot issues *

Footwear *

Cognitive Status

AMTS score *

Continence

Is the individual continent? *

Toilet frequency *

Nutrition, environment, function, balance & gait

Nutrition

Food intake *

Weight loss *

Number of drinks *

Environment

Home environment

Gait/Physical Activity

Walking at home *

Walking outside *

Walking aid *

Physical activity *

Physical activity change? *

Balance

Walking balance *

Functional Behaviour

Observed behaviours *

Functional

Personal assistance *

Personal assistance change?

Instrumental assistance *

Instrumental assistance change?

Listed medication

Does the individual take any of the following type of medication? Sedative, antidepressant, anti-epileptics, central acting analgesic, digoxin, diuretics, type 1a antiarrythmic, vestibular suppressant

Medical conditions

Does the individual have a chronic medical condition/s affecting their balance and mobility? Arthritis, respiratory condition, parkinson’s disease, diabetes, dementia, peripheral neuropathy, cardiac condition, stroke, other neurological conditions, lower limb amputation, osteoporosis, vestibular disorde, other dizziness, back pain, lower limb joint replacement

Vision deficit

Does the client have an uncorrected sensory deficit/s that limits their functional ability?

Somato deficit

Does the client have an uncorrected sensory deficit/s that limits their functional ability?

Foot issues

Does the client have foot problems, e.g. corns, bunions, swelling etc.

Footwear

Does the client have inappropriate, poorly fitting or worn footwear?

AMTS score

Age, time to the nearest hour, address to recall – 42 west st, current year, current location (where are we?), recognition of two persons (Dr, nurse), date of birth, years of first world war, name of current prime minister, count backwards from 20 by ones

Toilet Frequency

Does the individual regularly have to go to the toilet in the night (3 or more times, if uses a bottle, rate as no)?

Food intake

Has the individual’s food intake declined in the past three months due to a loss of appetite, digestive problems, chewing or swallowing difficulties?

Weight loss

Weight loss during the last 3–12 months – need the options

Number of drinks

Number of alcoholic drinks consumed in the past week

Home environment

Did the home environment appear safe? Note: only rate if undertaking a home visit assessment, leave blank otherwise

Observed behaviours

Observed behaviours in activities of daily living and mobility indicate

Personal assistance

Prior to this fall, how much assistance was the individual requiring for personal care activities of daily living (eg dressing, grooming, toileting)? Note: If no fall in last 12 months, rate current function

Personal assistance change?

Has this changed since the most recent fall? (leave blank if no falls in 12 months)

Instrumental assistance

Prior to this fall, how much assistance was the individual requiring for instrumental activities of daily living (eg shopping, housework, laundry)? Note: If no fall in last 12 months, rate current function

Instrumental assistance change?

Has this changed since the most recent fall? (leave blank if no falls in 12 months)

Walking Balance

Does the individual, upon observation of walking and turning, appear unsteady or at risk of losing their balance? Note: Rate with usual walking aid. Tick one only, if level fluctuates, tick the most unsteady rating

Walking at home

Can the individual walk safely around their own home?

Walking aid

If a walking aid is used, list the aid and when it is used.

Physical activity

How physically active is the individual?

Physical activity change?

Has this changed since the most recent fall?

Walking outside

Can the individual walk safely in the community?

Injury sustained in last 12 months?

Was an injury sustained in any of the fall/s in the past 12 months?