Hertfordshire Active Living

This form enables health professionals working with you to find out how you are managing at home, and whether you need any extra help to reduce your risk of falling and getting hurt in future. 

Anyone who is aged over 75, can fill in this form.  A carer, family member or a health professional - such as a doctor or nurse - can fill in the form with you if you need help.

If the answers you give show that you are at a higher risk of falling, the people involved in your care will be able to signpost you to further advice and support.

1Hertfordshire Active Living

2Section A

3Section B

4What next?

If you have answered ‘YES’ to any of the questions in Section A or if your total score in Section B is 4 or more, with your consent we may refer you to HertsHelp.

5If you answered the questions in this form and:

• you haven’t had any falls in the past year

• you don’t have any problems with getting to the toilet

• you are not experiencing memory problems,

• your total score added up to three or less

Then you are not currently considered to be at a high risk of losing your independence or falling.

See the Health in Herts website - www.hertsdirect.org/healthinherts for advice and tips on staying healthy and active at home or out and about, or visit your local library for information on clubs and healthy activities. If you want to speak to someone about any support needs that you have, call the county-wide advice line ‘HertsHelp’ on 0300 123 4044.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Your Neighbourhood Professionals. Just a Click Away! Need care but want to stay in your own home?
Little Bushey Surgery, California Lane, Bushey, Herts, WD23 1EZ
  • Telephone 020 8386 8888
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Your Neighbourhood Professionals. Just a Click Away! Need care but want to stay in your own home?
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