No history of falls Risk or fear of falls History of falls: Indoors Outdoors Date last fall: Falls Reason: Frequency: Pendant alarm in place Yes No Current situation Agencies/support networks involved Start date person Main carer: Informal Formal Carers Is a universal carer’s assessment required? Yes No Declined Not established (if relevant) Lives alone: Yes No Other people living at the property: Household structure Environmental details LBS Owner Occupier Private Landlord Housing Association City of London Landlord/HA contact details: Tenure Have you applied for rehousing? Yes No Reference number: House Flat Maisonette Bungalow Property layout Front access: Rear access: Layout of Ground floor: property First floor: Upper floors:
Falls No history of falls Risk or fear of falls History of falls: Indoors Outdoors Date last fall: Reason: Frequency: Pendant alarm in place Yes No Current situation Agencies/support networks involved Start date person Carers (if relevant) Main carer: Informal Formal Is a universal carer’s assessment required? Yes No Declined Not established Household structure Lives alone: Yes No Other people living at the property: Environmental details Tenure LBS Owner Occupier Private Landlord Housing Association City of London Landlord/HA contact details: Have you applied for rehousing? Yes No Reference number: Layout of property House Flat Maisonette Bungalow Property layout Front access: Rear access: Ground floor: First floor: Upper floors:
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