Southern Adelaide Local Health Network - Falls Prevention in SA

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Metropolitan Adelaide Falls Prevention Service Request Form Facsimile info Central Adelaide Please fax to 1300 467 567 PO Box 508. Prospect, SA, 5082 Northern Adelaide Please fax to 1300 467 567 PO Box 508. Prospect, SA, 5082 Southern Adelaide Please fax to 8201 7860 For all enquiries, please phone 1300 0 FALLS (1300 0 32 557) The SA Health Metro Area Falls Teams (Central, Northern & Southern) provide triaging for and linkage to falls prevention services in the Adelaide Metropolitan Area including Falls Assessment Clinics, In-Home Falls Risk Assessments and other community services/programs. Does your client require a falls risk assessment to avoid an imminent hospital admission? Yes > call Metropolitan Referral Unit on 1300 110 600 DO NOT COMPLETE THIS FORM No > Complete this form Patient information Patient name: Hospital UR No: GP Name: Address: DOB: ATSI: No Yes Address: Preferred contact time/method: Phone no: Phone no: Fax no: NOK: Contact no 1: Contact no 2: Past Medical History (attach summary) Interpreter required: No Yes Language spoken: Medication (attach details) History of Presenting Complaint and Reason for Referral (please indicate if your request is specifically for a Geriatrician led Falls Assessment Clinic) Community Services Is the patient receiving other community service? No Yes > Dom. Care DVA Gold/White Card Holder CACPS HACC Private other Referrer Name (please Print): Designation/Organisation: Phone number: Date: For more information on available falls prevention services - see Falls Prevention Service Directories - Central, Northern & Southern www.fallssa.com.au
Referral Form for Day Therapy Services in Southern Region To the Coordinator of... CC: General Practitioner for information and follow-up __________________________________________________________________________________________________ Patient Details / Affix Sticker Ability to speak understand English No Yes Language Spoken __________________________________ Aboriginal/TSI No Yes NOK/Contact Person: _______________________________________________________________________________ Past medical history _______________________________________________ _______________________________________________ _______________________________________________ Current medications _______________________________________________ _______________________________________________ _______________________________________________ Reason for Referral __________________________________________________________________________________________________ __________________________________________________________________________________________________ Service(s) Requested Physiotherapy Podiatry Dietician Speech Pathology Occupational therapy Other: ________________________________________________________________ Client is suitable to participate in a group program No Yes Are there any limitations or movements that should be avoided No Yes Referring person (if not the GP): General Practitioner: Name: _________________________________________ Relationship/Agency: _____________________________ Address: ________________________________________ ______________________ Post code: ________________ Contact phone number: __________________________ Date: ___________________________________________ Signature: _______________________________________ Name: _________________________________________ Relationship/Agency: _____________________________ Address: ________________________________________ ______________________ Post code: ________________ Phone: _______________ Fax: _____________________ Date: ___________________________________________ Signature: _______________________________________ Commonwealth Department of Health and Ageing funds Day Therapy Services Please Note: A fee for service applies, however fee waiver can be arranged for those with demonstrated financial need.
Page 1 and 2: Falls Prevention Service Directory
Page 3 and 4: A word from our General Manager The
Page 5 and 6: Access to Falls Prevention Services
Page 7 and 8: Repatriation General Hospital Falls
Page 9 and 10: Southern Area Day Therapy Centres L
Page 11 and 12: Private Hospital Day Therapy Option
Page 13 and 14: Councils in the Southern Area Counc
Page 15 and 16: Vestibular Services - Private Busin
Page 17 and 18: Continence services The listed cont
Page 19 and 20: Relevant Services in the Southern R
Page 21: Referral Forms - Southern Adelaide
Page 25 and 26: Strength for Life 50+ Referral Form
Page 27 and 28: Strength for Life Location Map 6 11
Page 29 and 30: Falls Prevention Resources 4. Fact
Page 32: For more information Southern Adela

Southern Adelaide Local Health Network - Falls Prevention in SA

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