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{\header\pard\tqc\tx4153\tqr\tx8306\tx13608\tx20412\tx27216\plain\f0\fs28 CNAHS FALLS ASSESSMENT CLINIC\par\pard\tqc\tx4153\tqr\tx8306\tx13608\tx20412\tx27216 REFERRAL FORM\par}
{\footer\trowd\trgaph108\trleft0\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrb\brdrs\brdrw10\cellx3828\clvertalt\clbrdrb\brdrs\brdrw10\cellx7230\clvertalt\clbrdrb\brdrs\brdrw10\cellx10095\pard\widctlpar\intbl\pard\intbl\qc\tx6804\tx13608\tx20412\tx27216\plain\f0\fs20 Patient Name\cell\pard\intbl\qc\tx6804\tx13608\tx20412\tx27216 Patient DOB\cell\pard\intbl\qc\tx6804\tx13608\tx20412\tx27216 Referral Date\cell\intbl\row\pard\trowd\trgaph108\trleft0\trpaddl108\trpaddt0\trpaddr108\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\cellx3828\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\cellx7230\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\cellx10095\pard\widctlpar\intbl\pard\intbl\qc\tx6804\tx13608\tx20412\tx27216{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f0\fs20\cell\pard\intbl\qc\tx6804\tx13608\tx20412\tx27216{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:DOB>>{\*\txfieldend}\plain\f0\fs20\cell\pard\intbl\qc\tx6804\tx13608\tx20412\tx27216{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f0\fs20\cell\intbl\row\pard\pard\qc\tx6804\tx13608\tx20412\tx27216{\txfielddef{\*\txfieldstart\txfieldtype3\txfieldflags0}{\*\txfielddatadef\txfielddatatype3\txfielddata 00030001}{\*\txfieldtext \plain\f0\fs20 2}{\field{\*\fldinst {\plain\f0\fs20 PAGE }}{\fldrslt{\plain\f0\fs20 1}}}}\par}\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs14\b\par\plain\f0\fs22\b FAX THIS FORM TO CENTRAL FAX NUMBER: 1300 467 567\par                                   CENTRAL PHONE NUMBER: 1300 0 FALLS (1300 0 32557)     \plain\f0\fs14\b\par\par\plain\f0\fs16\b Falls Assessment Clinics (Physical Addresses):\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx2253\clvertalt\cellx4698\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Hampstead Centre\par\plain\f0\fs14 Day Rehabilitation Centre\par 207-255 Hampstead Rd\par Northfield SA 5085 \plain\f0\fs16\b\cell The Queen Elizabeth Hospital\par\plain\f0\fs14 Area 4, Outpatient Clinic\par 28 Woodville Road\line Woodville South, SA 5011\plain\f0\fs16\b\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs24\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx10131\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20 PATIENT DETAILS\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx4866\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx10131\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20\b Given Names: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs24\b\ul <<Patient Demographics:First Name>>{\*\txfieldend}\plain\f0\fs20\par\plain\f0\fs20\b Surname:\plain\f0\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs24\b\ul <<Patient Demographics:Surname>>{\*\txfieldend}\plain\f0\fs20\par\plain\f0\fs20\b Address:\plain\f0\fs20  \par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Full Address>>{\*\txfieldend}\plain\f0\fs20\b\par Date of Birth:{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:DOB>>{\*\txfieldend}\plain\f0\fs20\b\par\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20\b Phone:\plain\f0\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Phone (Home)>>{\*\txfieldend}\plain\f0\fs20 (Home) \par\par\plain\f0\fs20\b Contact Person:\plain\f0\fs20  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0043007c00320030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs20 <<Contact Person (if not the patient)>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|C|20||0|"}}{\fldrslt{\plain\f0\fs20 <<Contact Person (if not the patient)>>}}}}\plain\f0\fs20\par\plain\f0\fs20\b Phone:\plain\f0\fs20  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004e007c00310035007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs20 <<Contact Person's Phone Number>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|N|15||0|"}}{\fldrslt{\plain\f0\fs20 <<Contact Person's Phone Number>>}}}}\plain\f0\fs20\b\cell Interpreter Required:\plain\f0\fs20  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Interpreter Required?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Interpreter Required?>>}}}}\plain\f0\fs20\b\par Language:\plain\f0\fs20  {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0043007c00320030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs20 <<Language>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|C|20||0|"}}{\fldrslt{\plain\f0\fs20 <<Language>>}}}}\plain\f0\fs20  \par\plain\f0\fs20\b ATSI:\plain\f0\fs20  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<ATSI?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<ATSI?>>}}}}\plain\f0\fs20\par\par\plain\f0\fs20\b Medicare Number:\plain\f0\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Medicare Number>>{\*\txfieldend}\plain\f0\fs20\par\plain\f0\fs20\b Pensioner:\plain\f0\fs20  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Pensioner?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Pensioner?>>}}}}\plain\f0\fs20     {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:Pension Number>>{\*\txfieldend}\plain\f0\fs20\b\par DVA: {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<DVA?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<DVA?>>}}}}\plain\f0\fs20     {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Patient Demographics:DVA Number>>{\*\txfieldend}\plain\f0\fs20\b\par Dom Care Client:\plain\f0\fs20  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Dom Care Client?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Dom Care Client?>>}}}}\plain\f0\fs20\b\par Private Health:\plain\f0\fs20  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20 <<Private Health Insurance?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20 <<Private Health Insurance?>>}}}}\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft6\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx10116\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\plain\f0\fs20 MEDICAL INFORMATION\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft6\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx10116\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Past Medical History:\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 59000000}{\*\txfieldtext \plain\f0\fs20 <<Clinical Details:History List>>}{\field{\*\fldinst { HYPERLINK "Y" }}{\fldrslt{\plain\f0\fs20 <<Clinical Details:History List>>}}}}\plain\f0\fs20\b\par\par Allergies: \par{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfieldbin\txfielddata 0000}{\*\txfieldtext \plain\f0\fs20 <<Clinical Details:Allergies>>}}\plain\f0\fs20\par\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft6\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx10116\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Current Medications:\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Clinical Details:Medication List>>{\*\txfieldend}\plain\f0\fs20\b\par\plain\f0\fs20\par\plain\f0\fs20\b\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\par\plain\f0\fs20 ELIGIBILITY REQUIREMENTS FOR FALLS ASSESSMENT CLINIC\par THE PATIENT MUST: {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c00320031007c005400690063006b00200061006c006c00200062006f007800650073002000620065006c006f0077005e000000}{\*\txfieldtext \plain\f0\fs20 <<Patient MUST meet eligibility requirements below(*)>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||21|Tick all boxes below^"}}{\fldrslt{\plain\f0\fs20 <<Patient MUST meet eligibility requirements below(*)>>}}}}\plain\f0\fs20\b\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrt\brdrs\brdrw10\cellx1068\clvertalt\clbrdrt\brdrs\brdrw10\cellx10113\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c0053007c0031007c0059000000}{\*\txfieldtext \plain\f0\fs20\b <<Patent lives in the CNAHS region (*)?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B||S|1|Y"}}{\fldrslt{\plain\f0\fs20\b <<Patent lives in the CNAHS region (*)?>>}}}}\plain\f0\fs20\b\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20 Live in the CNAHS region \plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1068\clvertalt\cellx10113\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c0053007c0031007c0059000000}{\*\txfieldtext \plain\f0\fs20\b <<Patient consents to referral (*)?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B||S|1|Y"}}{\fldrslt{\plain\f0\fs20\b <<Patient consents to referral (*)?>>}}}}\plain\f0\fs20\b\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20 Consent to referral to Falls Assessment Clinic\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1068\clvertalt\cellx10113\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c0053007c0031007c0059000000}{\*\txfieldtext \plain\f0\fs20\b <<Patient aged 65 or older (>45 ATSI) (*)?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B||S|1|Y"}}{\fldrslt{\plain\f0\fs20\b <<Patient aged 65 or older (>45 ATSI) (*)?>>}}}}\plain\f0\fs20\b\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20 Be aged 65 or older (or >45 ATSI)\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1068\clvertalt\cellx10113\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c0053007c0031007c0059000000}{\*\txfieldtext \plain\f0\fs20\b <<Patient has multiple co-morbidities (*)?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B||S|1|Y"}}{\fldrslt{\plain\f0\fs20\b <<Patient has multiple co-morbidities (*)?>>}}}}\plain\f0\fs20\b\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20 Suffer from multiple co-morbidities\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1068\clvertalt\cellx10113\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c0053007c0031007c0059000000}{\*\txfieldtext \plain\f0\fs20\b <<Not attending another multidisciplinary program (*)?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B||S|1|Y"}}{\fldrslt{\plain\f0\fs20\b <<Not attending another multidisciplinary program (*)?>>}}}}\plain\f0\fs20\b\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20 Not currently be attending another multidisciplinary program\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1068\clvertalt\cellx10113\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c0053007c0031007c0059000000}{\*\txfieldtext \plain\f0\fs20\b <<No acute fracture and is medically stable (*)?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B||S|1|Y"}}{\fldrslt{\plain\f0\fs20\b <<No acute fracture and is medically stable (*)?>>}}}}\plain\f0\fs20\b\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20 Not have an acute fracture or an acute illness (i.e. the patient is medically stable)\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1068\clvertalt\cellx10113\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20\b <<Has has 2 or more falls in last year (*)?, OR>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20\b <<Has has 2 or more falls in last year (*)?, OR>>}}}}\plain\f0\fs20\b\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20 Have had \plain\f0\fs20\ul 2 or more\plain\f0\fs20\loch\f0\hich\f0 \~falls in the past 12 months \plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx1068\clvertalt\cellx10113\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20\b\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608                     \plain\f0\fs20\b\i or\plain\f0\fs20\b\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrb\brdrs\brdrw10\cellx1068\clvertalt\clbrdrb\brdrs\brdrw10\cellx10113\pard\widctlpar\intbl\pard\s16\intbl\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f0\fs20\b <<Has had 1 fall with serious injury in last year (*)?>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|B|||1|N"}}{\fldrslt{\plain\f0\fs20\b <<Has had 1 fall with serious injury in last year (*)?>>}}}}\plain\f0\fs20\b\cell\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20 Have had \plain\f0\fs20\ul 1 fall with serious injury\plain\f0\fs20  in the past 12 months\plain\f0\fs20\b\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\par\plain\f0\fs20 REASON FOR REFERRAL\plain\f0\fs20\b\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx10098\pard\widctlpar\intbl\pard\s16\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0043007c0030007c007c0030007c000000}{\*\txfieldtext \plain\f0\fs20 <<Reason for referral>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|C|0||0|"}}{\fldrslt{\plain\f0\fs20 <<Reason for referral>>}}}}\plain\f0\fs20\b\par\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx10101\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20 GENERAL PRACTITIONER DETAILS AND SIGNATURE\plain\f0\fs20\b\ul\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrt\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx10101\pard\widctlpar\intbl\pard\s16\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20\b General Practitioner Name: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20\b\ul <<Doctor:Name>>{\*\txfieldend}\plain\f0\fs20\b\par Practice Address: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Full Address>>{\*\txfieldend}\plain\f0\fs20\b\par Provider Number: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Provider Number>>{\*\txfieldend}\plain\f0\fs20\b\par Phone: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Phone>>{\*\txfieldend}\plain\f0\fs20\b\par Fax: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Doctor:Fax>>{\*\txfieldend}\plain\f0\fs20\b\par\par General Practitioner Signature:\plain\f0\fs20 ........................................................          \plain\f0\fs20\b Date:\plain\f0\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Miscellaneous:Date>>{\*\txfieldend}\plain\f0\fs20\par\plain\f0\fs20\b\cell\intbl\row\pard\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\par\par\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\plain\f0\fs20 INVESTIGATION RESULTS\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrt\brdrs\brdrw10\cellx10885\pard\widctlpar\intbl\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f0\fs20 <<Summary:Investigation Results (Selected)>>{\*\txfieldend}\plain\f0\fs20\par\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\tx13608\par 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