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.

Name

Date of Birth

Section A

Do you have difficulty getting to the loo in time at home?

Are you unsteady or have you had a fall in the past year?

Are you finding it more difficult to remember things?

Section B

Are you aged over 85?

Are you male?

Do you have any health problems that limit your activities?

Do you need someone to help you on a regular basis?

Do you have any health problems that require you to stay at home?

Can you count on someone in time of need?

Do you often use a stick, frame or wheelchair to get around?

Please add up all of your scores, what is your total?

What 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.

Please tick the box if you agree to be referred to HertsHelp.

If 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.

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This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Little Bushey Surgery • Little Bushey Surgery, California Lane, Bushey, Herts, WD23 1EZ.

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Key Information

Hertfordshire Active Living

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