UCR COMMUNITY FALLS ASSESSMENT: REFERRAL FORM	
Please complete this form in full as incomplete forms will be returned / rejected	

REFERRAL CRITERIA - If they are unable to satisfy the below then please refer to a more appropriate service:
Aged 50+ years old and has consented to the referral/review                                Yes   No            
Newham resident with a Newham GP                                                                               Yes   No         
They must either have a history of 2 or more falls within the past 6 months or be frightened of falling/have concerns or a lack of confidence with their balance or mobility (with severe impact on activities of daily living).                                                                                                        Yes    No        
Would not benefit from single HCP intervention e.g. physiotherapy                     Yes   No        
i.e. needs Multi-Factoral Falls Assessment by two or more professions See NICE - Clinical guideline [CG161]
Polypharmacy (patient is on 4 or more medications.)                                                  Yes    No        
Please discuss with the UCR duty triage therapist 0208 709 5555 if you have any questions.
Exclusion criteria
Fall due to an acute episode of illness (if appropriate please refer by telephone 02087095555 to rapid response)
Under 50 years old
Patient unaware of referral.
Falls due to ongoing drugs/alcohol dependency.	
PATIENT’S DETAILS	
Forename(s): 	
Surname:                                       	M        F   	

Title: 	DOB: 
	Contact number: 	
NHS Number: 	
Address: (Please include access details if known key safe number etc): 
Next of Kin Name/ Relationship to Patient/ Contact Details:  	
Patient lives alone?    
Yes         NO   	Can open door?
Yes      NO   
	Any known social issues or risks associated with this patient?
Yes         NO 	
Reason for referral:  	
GP DETAILS	
GP Address 	

GP Name/stamp: 	
REFERRER DETAILS (if not GP)	Job Title: 	Contact Tel: 	
Name: 	Team & Base: 	
Date & Sign:  	
Please return this referral form to the single point of access (SPA):
Email:  epct.spa@nhs.net
Contact number: 0208 709 5555