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?