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