To increase awareness on what you can do to prevent falls, we are inviting members of the public to take part in a short survey that will take 5 to 10 minutes to complete. 
If you provide your email address or postal address at the end of this survey, we can send you a copy of your completed survey for discussion with your family, Carer, GP or healthcare professional to support you to put in place your own falls prevention plan.
Your personal information will not be used for any other purpose.

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* 1. DATE

Date

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* 2. [FOR OUR RECORDS ONLY PLEASE TELL US:]

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* 3. Age

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* 4. Which Council area do you live in?

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* 5. How did you find out about this survey?

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* 6. Are you afraid of falling?

Why it matters:
People who are worried about falling are more likely to fall. Fear of falling can have a significant impact on quality of life in older people.

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* 7. Have you fallen in the past year?

Why it matters:
People who have fallen once are likely to fall again. A third of people aged 65 and older fall at least once per year with 5% of these falls resulting in a fracture.  In nursing homes, fall rates are higher with almost half of residents falling more than once a year.  The main consequences of falls in older people are fractures, traumatic brain injury, damage to internal organs, spinal and nerve injuries, joint dislocation, soft tissue damage, bruises and cuts.

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* 8. How did you answer?

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* 9. How concerned are you about falling or losing your balance?

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* 10. How many times did you fall in the LAST 3 months?

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* 11. Did any fall cause an injury? 

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* 12. How many times did you fall in the LAST 12 months (1 year)?

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* 13. Did any fall cause an injury?

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* 14. How many times did you fall in the LAST 12 - 24 months (2 year)?

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* 15. Did any fall cause an injury? 

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* 16. In the event of a fall, can you get up from the floor without help?

Why it matters:
If an older person is unable to get up from the floor after a fall, they are at risk of having a long lie which can lead to many complications. For example; pressure sores, delayed medical treatment, pneumonia, fear of falling, rhabdomyolysis i.e. muscle and tissue damage, carpets burns, dehydration, hypothermia, kidney damage.
A long lie is defined as being on the floor for an hour or more and is a marker of weakness, illness and social isolation.

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* 17. In the event of a fall do you have a plan to prevent a long lie?

Why it matters:
A long lie is when a person who has fallen spends a long period of time on the floor because they are unable to get up. A long lie is define as being on the floor for an hour or more. 
20% of fallers who have attended the Emergency Department have been found to have been on the floor for an hour of more.
A study of 125 adults over 65 years of age has found that half of those who lay on the floor for more than one hour went on to die within the following 6 months even without a direct injury from the fall.
The best way to prevent a long lie is to prevent falls. Wearing a personal alarm or carrying a charged mobile phone can ensure that you do not have a long lie as you are able to contact someone to let them know that you need help. Ensure the person you call knows how to access your home. For support in making your falls action plan - Know who to call if you have a fall, speak to your family, friends or healthcare provider .

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* 18. How OFTEN do you lose your balance or almost fall WITHOUT actually falling?

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* 19. Do you feel unsteady or need to hold onto furniture when walking at home?

Why it matters:
Unsteadiness or needing support while walking are signs of poor balance and may be caused by a loss of muscle strength with age, reduced vision, alcohol, medications or hazards in the environment. Check with your local healthy living centre and / or leisure centre for opportunities to do physical activity that builds and maintains balance, muscle strength and bone density. Alternatively, speak to your doctor or healthcare provider for further advice.

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* 20. Do you struggle to get up from a chair without using your arms for support?

Why it matters:
This is a sign of weak leg muscles, a major reason for falling. Speak to your GP or healthcare provider for further advice.

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* 21. Do you have trouble stepping up on onto a kerb?

Why it matters:
This is a sign of muscle weakness. Stop at kerbs and check the height before stepping up or down.  Be careful at kerbs that are uneven or have been cut away to allow access for bikes or wheelchairs. The incline may lead to a fall. If you are wearing bi / vari-focal glasses, be careful as lenses may increase your risk of falls. Speak to your doctor or healthcare provider regarding services that are available to support you with improving your strength, balance and mobility.

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* 22. Are there areas around your home which you feel present a higher risk of causing you to fall?

Why is this important:
Simple changes within your home such as having clear walkways, removing mats, trip hazards and clutter together with ensuring that you have good lighting can reduce your risk of falls. The local councils have Home Safety Officers who can visit your home to provide support and guidance on reducing the risk of accidents such as falls in your home. Speak to your GP or healthcare provider if you require further support / information.
Check out the link for your local council for further information, copy and paste link in your search engine.
Or telephone the helpdesk on the numbers below for further information.
Derry and Strabane 
https://www.derrystrabane.com/homesafety
02871 253253
Fermanagh and Omagh
https://www.fermanaghomagh.com/services/community/environmental-health/home-safety/
0300 3031777
Causeway Coast and Glens
https://www.causewaycoastandglens.gov.uk/live/health-and-built-environment/environment-health-and-well-being/wellbeing/home-safety
02877 760302

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* 23. Do you need to rush to the toilet?

Why it matters:
Rushing to the bathroom , especially at night increases your chance of falling. Speak to your healthcare provider to discuss services that may support your continence needs.

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* 24. Do you have problems with your feet eg numbness, pain, corns, calluses, nails?

Why it matters:
Numbness, pain, discomfort can increase your risk of falls. Consider if you could benefit from podiatry support.

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* 25. Do you wear good fitting secure footwear?

Why it matters:
Poor fitting or inappropriate footwear increases your risk of falls.

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* 26. Do you take 4 or more medications?

Why it matters:
All medications have side effects and some could increase your risk of falls.

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* 27. Do you take medicine that makes you feel light headed or more tired than usual?

Why it matters:
Side effects from medicines can sometimes increase your risk of falling. Speak to your GP or Pharmacist for further advice.

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* 28. Do you take medicine to help you sleep?

Why it matters:
These medicines can sometimes increase your risk of falling.

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* 29. Do you take medicine to improve your mood?

Why it matters:
These medicines can sometimes increase your risk of falling.

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* 30. Have you had your medications reviewed in the last year?

Why it matters:
It is important to discuss all medications that you are currently taking with your Pharmacist or GP especially if you are feeling dizzy, light headed, drowsy or experience other adverse effects that you feel may be related to your medication.

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* 31. Have you had an assessment of your bone health?
If you have not been diagnosed with osteoporosis or had a bone health assessment, check out the osteoporosis risk checker below to get a personalised report on your bone health.

This risk checker is not designed for people who have already been diagnosed with osteoporosis or have had their bone health assessed by a healthcare professional. 

Osteoporosis risk checker (theros.org.uk)

https://theros.org.uk/risk-checker/?campaign=77a866ee-c708-ed11-82e5-0022481b5a28

The risk checker is not a diagnostic tool.  It is intended to raise awareness of factors that are known to increase the risk of developing osteoporosis and broken bones.

The Royal Osteoporosis Society also have a free helpline which can provide tailored information and support about osteoporosis and bone health. The helpline is open Monday to Friday 9am – 5pm with lunch 12.30-1.30pm. 

Get in touch by calling 0808 800 0035 or emailing nurses@theros.org.uk.

If you think that you might be at risk of osteoporosis or breaking a bone easily, speak to your GP or healthcare professional in the first instance.  If you have a medical condition that is known to increase the risk of osteoporosis, you may want to mention bone health to your specialist at your next appointment.

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* 32. Do you often feel sad or depressed?

Why it matters:
Symptoms of depression, such as not feeling well or feeling slowed down are linked to falls. Speak to your GP or healthcare provider for further advice/ support

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* 33. Have you had your eyes tested in the past year?

Why it matters:
Misuse of prescribed glasses has been linked to falls. Poor eyesight, poor lighting and use of bi / vari focal glasses have been linked to falls. Our eyes change as we get older and we are more likely to develop eye disease. Make an appointment with your optometrist for an eye examination to keep your eyes healthy. Tell your optometrist about your history of falls

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* 34. Have you contacted your GP to discuss your risk of falls?

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* 35. Have you contacted your social worker or a social worker in your GP practice to discuss your risk of falls?

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* 36. Have you contacted or received follow up in relation to your risk of falls from a Nurse?

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* 37. Have you had a medication review in relation to your risk of falls from a Pharmacist?

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* 38. Have you received follow up in relation to your risk of falls from a Physiotherapist?

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* 39. Have you received follow up in relation to your risk of falls from a Falls Occupational Therapist?

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* 40. Have you received follow up in relation to your risk of falls from a Community Occupational Therapist?

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* 41. Have you received follow up in relation to your risk of falls at a Care Of The Elderly Falls Clinic?

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* 42. Have you received follow up from the Stepping On -  Over 65s Falls Prevention Programme?

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* 43. Have you had a visit from the Council Home Safety Officer in relation to prevention of home accidents?

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* 44. Has Northern Ireland Ambulance Service (NIAS) attended you following a fall?

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* 45. Have you attended the Emergency Department following a fall?

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* 46. Were you admitted to hospital as a result of a fall?

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* 47. Would you like to receive a copy of your falls report that you can share or discuss with your GP/Healthcare provider, carer or family to support you in making a plan to prevent further falls.

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* 48. Would you like to receive falls information booklets on ways to reduce your risk of falls together with information on services that are available to support you with falls prevention?

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* 49. How would you like to receive your information?

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* 50. Enter your email address below if you have consented to receive the information outlined.

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* 51. Enter your name and postal address below if you would prefer to receive the outlined information by post.

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* 52. Would you be interest in being contacted to become a member of a service user group to help improve falls services?

For more information on how to reduce your risk of falling, check out the following link
https://westerntrust.hscni.net/healthy-living/later-years/
Data Protection

In accordance with the Data Protection Act 2018, the Western Health and Social Care Trust has a duty to protect any information we hold on you. The personal information you provide on this form will only be used for the purpose of the delivery of falls prevention services and to produce statistical reports. For further guidance on how we hold your information please visit the Privacy section at
https://westerntrust.hscni.net/about-the-trust/access-to-information/personal-information/

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