Skip to main content
Services In My Area
Toggle navigation
1800 275 753
BA+
Please ensure Javascript is enabled for purposes of
website accessibility
Fulltext search
Search
Top Navigation
Accessibility
Careers
Donate
Pricing Information
Services In My Area
Main navigation
How We Help
Just Diagnosed
Parents & Carers
Kids
Seniors
Teenagers & School Leavers
Teachers & Schools
Adults
NDIS
Services
Disability Support
Home Support
Creative, Recreational & Life Skills Programs
Employment Services
Therapies
Housing Options
Getting Into Your Community
Aged Care
Pay for services
Resources
Pricing Information
Understanding Disability
Library
Queensland Cerebral Palsy Register
Touchstone Magazine
Research
About CPL
CPL - Choice, Passion, Life
News
The CPL Team
Events
Reconciliation Action Plan
Work with us
Support Us
Donate
Partner with us
Fundraise for CPL
Contact Us
Get In Touch
Our Locations
Feedback and Complaints
You are here:
Home
Form
Falls prevention and mobility ch
Falls Prevention & Mobility Checklist
Client name:
Client's date of birth:
Reason for referral:
Available government funding source
NDIS plan
Home care package
DS/HACC
Continuity of Care funding (+65)
None
Does the client prefer to use FFS for this referral?
Yes
No
Preferred outcome (if known) e.g. assessment, new wheelchair, transfer docs:
Checklist completed by:
Relationship to client:
Service, location and client address (e.g. Support at home - Fig Tree Pocket, 17 Rosella St, Fig Tree Pocket):
Who to contact to set appointments (key contact name):
Relationship of key contact to client:
Key contact details - phone:
This checklist needs to be filled out in consultation with someone who is familiar with the client’s mobility. Please rate the following statements and action referral to CPL physiotherapists for review of mobility and falls risk. It is mandatory to make a referral to CPL physiotherapist when a) any items from 1-6 have been checked or B) 3 or more checklist items in total have been checked:
Please select
I accept
1. Has the person fallen in the last 12 months?
Please select
No
1 fall
2 falls
3 or more
2. Was an injury sustained in any of the fall/s in the past 12 months? (rate most severe injury due to a fall in the past 12 months)
Please select
No
Minor – no medical attention
Moderate – medical attention
Severe injury (fracture etc.)
3. When walking or turning what is the risk of the person losing their balance? Consider how unsteady they look when walking or turning to make your rating.
Please select
No risk of losing balance
Minimal risk of losing balance
Moderate risk of losing balance
Severe risk of losing balance
4. Can the person walk safely around their own home?
Please select
Yes
Yes with aid
Safe with supervision
Unsafe
5. Can the person walk safely in the community?
Please select
Yes
Yes with aid
Safe with supervision
Unsafe
6. Does the home environment appear safe?
Please select
Yes
Minimal hazards
Moderate hazards
Extreme hazards
7. If a walking aid is used, list the aid and when it is used?
Please select
Indoors
Outdoors
Aid
7.1 Please specify what aid is used:
8. Prior to this fall, how much assistance was the person requiring for activities of daily living (e.g. dressing, grooming, toileting, shopping)? (NOTE: If no fall in last 12 months, rate current function)
Please select
None
Supervision
Some assistance
Completely dependent
9. Has this changed since the most recent fall? (leave blank if no falls in last 12 months)
Please select
No
Yes
Often
9.1 Please specify:
10. How physically active is the person?
Please select
Inactive
Rarely leaves house
Exercises twice/week
Exercises 3 times/week
11. Does the person currently have an exercise program?
Please select
Yes
No
Comments:
Submit form
Leave this field blank