Age-friendly Primary Health Care Centres Toolkit - World Health ...

AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKITWhat for ?By whom ?How long ?Tool 6: Falls evaluation formInvestigation of the origin of fallsPart 1: Nurse or trained health care workerPart 2: Medical doctor20 minutesPART 1Name:_____________ Age:_______________ Date:_________________History of Your FallsDescription of the fallWe need to hear the details of your falls so we can understand what is causingthem. Answer the following questions about your last fall.When was this fall? _____________________________________________Date (approximate) ___________ Time of Day ________________________• What were you doing before you fell?• Do you remember your fall, or did someone tell you about it?• How did you feel just before?• How did you feel going down?• What part of your body hit?• What did it strike?• What was injured?• Anything else you recall?• Do you think you passed out?• Do you have joint pain?• Do you have joint instability?• Do you have foot problems?• Do you use a cane/walker?How often have you fallen in the past six months?63