There are 23 questions in this survey.
Number of days between the fall incident and the consultation?
Previous fall in last 12 months?
Present risk factors / possible causes of fall incident?
Behavior and environment risk factors / causes of fall incident: specify
Have measures been taken or planned to address existing risk factors / fall prevention?
Adjustment / reduction medication: specify
Approach for environment and walking problems: specify
Has there been any consultation or planned counsel with other care providers (in or outside your practice) about the preventive measures for this patient?