There are 25 questions in this survey.

1. Identification

GP code

Startdate of consultation week (monday)

Format: mm-dd-yyyy

Sex patient
Agegroup patient
65 - 69 year
70 - 74 year
75 – 79 year
80 – 84 year
85 – 89 year
>=90 year
Which type of IDcard your patient possess?
Does the patient has access to OMNIO/BIM statute, urgent medical aid, CPAS/OCMW or other financial help?

2. Fall incidents

Number of days between the fall incident and the consultation?

Previous fall in last 12 months?

Severity of the injuries?
No injuries
Little or no care needed (abrasions, contusions, skin wounds, cuts that do not require adhesion, ...) (class 1)
Medical and / or nursing intervention required (sprains, large and/or deep cut wounds, skin wounds or small bruises / interventions: adhesion, bandage, splint or ice bag) (class 2)
Fractures, loss of consciousness, changes in mental and/or physical state (class 3)
Was it decided during the consultation to refer the patient to the hospital?
Awaiting a decision/not decided yet
Location of fall incident?
At home (private domicile)
In a residential care centre
In the immediate vicinity of own home or residential care centre
Time of day of fall incident?
In the morning
During the afternoon
In the evening
During the night
Activity when falling?
Activity in function of daily basic physical needs (ADL)
Housekeeping or jobs in/around the house
Leisure, shopping, sports,...

Present risk factors / possible causes of fall incident?

Person related
Behavior and environment
No risk factors present / unidentifiable

3. Fall prevention

Have measures been taken or planned to address existing risk factors / fall prevention?

Has there been any consultation or planned counsel with other care providers (in or outside your practice) about the preventive measures for this patient?