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Falls & Fracture Prevention Self-Assessment Tool
Electronic
Falls & Fracture Prevention• XXXXX is committed to improving the
healthcare of our service users.
• This electronic tool can assess your risk of fracturing and falling. It can also directly link with your GP giving him/her all details required to improve your health. All information is secure, encrypted and protected.
• This tool plays a very important part of your visit to XXXX and we would be delighted for your participation
MRN
Type in Your GPs Name
SELECT
John John Stillorgan
DATE OF BIRTH
24 JUNE 1964
WHAT’S YOUR HEIGHT?
Feet Inches
WHAT’S YOUR WEIGHT?
Stone Pounds
PLEASE COMPLETE THE FOLLOWING
QUESTIONS
DO YOU HAVE OSTEOPOROSIS?
Yes No
DID ONE OF YOUR PARENTS HAVE A HIP
FRACTURE?
Yes No
HAVE YOU BROKEN A HIP, WRIST, ANKLE OR SHOULDER
IN THE PAST FEW YEARS?
Yes No
DO YOU HAVE RHEUMATOID ARTHRITIS?
Yes No
ARE YOU TAKING STEROID TABLETS?
Yes No
DO YOU SMOKE?
Yes No
DO YOU DRINK ALCOHOL?
Yes No
More than 2 ½ Bottles of Wine10 Pints of Beer/Stout8 Large Glasses of Spirits- Per Week
DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS?
Yes
NoCOPDYes
NoOrgan
TransplantYes
NoType I
Diabetes
Yes
NoLiver
DiseaseYes
NoGastrointestinal
Disease
Yes
NoHyperthyroidism
HAVE YOU HAD A FALL IN THE PAST YEAR,
INCLUDING A SLIP OR A TRIP?
Yes No
DO YOU HAVE DIFFICULTIES WITH YOUR WALKING OR
BALANCE?
Yes No
DO YOU HAVE A FEAR OF FALLING?
Yes No
IF YOU DID HAVE A FALL, DID YOU
Yes
NoBlackout, Get Dizzy, Chest painYes
No
Yes
No
Remember Falling?
Get Up From the Floor?
DO YOU THINK YOU HAVE ANY OF THE FOLLOWING ISSUES?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Strength/Balance Problems
Impaired Vision
Issues withContinence
Taking Many Medications
Pain/Aches/Soreness
Difficulties dressing or toileting
Results
YOUR RISK OF FRACTURE IS:
HIGH
HIGH• It is very common to be at high risk of
fracture in Ireland
• Over 50% of women and 20% of men are at risk of a fracture
• You should contact your GP to discuss a plan of treatment
YOUR RISK OF FRACTURE IS:
INTERMEDIATE
INTERMEDIATE• It is very common to be at intermediate risk
of fracture in Ireland
• Over 50% of women and 20% of men are at risk of a fracture
• You should contact your GP to discuss undergoing a bone scan (DXA) and a plan of treatment
YOUR RISK OF FRACTURE IS:
LOW
LOW• Over 50% of women and 20% of men are at
risk of a fracture
• Though your risk is low, we recommend continuing with adequate amounts of sunshine, regular weight bearing exercise and a healthy balance diet
• Please review irishosteoporosis.ie for advice on maintaining healthy bones
YOU ARE AT RISK OF FALLING
• Over ⅓ of people over 65 and ½ of all people over 80 will fall every year
• Please review fallsprevention.ie for advice on preventing falls
Recommendations
• Based on what was selected
• Ability to print may be required
• email to GP also
THANK YOU FOR PARTICIPATING
Overall
• End point for this to go hospital-wide
• Opportunity to systematically assess 35,000 people for risk of fracture/osteoporosis and to seamlessly link with the patients GP to reduce disability, death, cost, length of stay and to contribute to positive ageing