Wide Bay Hospital and health Service
Integrated Care Services
WIDE BAY FALL 
PREVENTION SERVICE
Referral Form
Referral to: <Referral To>	URN: 
Family Name: <PtSurname>
Given Name(s): <PtFirstName> <PtMidName>
Address: <PtAddress>
Date of Birth: <PtDoB>
Sex: <PtSex>	
Date: <TodaysDate>          QAS Incident Number: 	
<Patient's verbal consent> Patient's verbal consent
<Consent>	
Patient details	
Name:	<PtFullName>	
Address:	<PtAddress>	
Phone Number:	Home: <PtPhoneH>         Mobile: <PtPhoneMob>	
Date of Birth:	<PtDoB>          Age: <PtAge>	
Gender:	<PtSex>	
Does the patient identify as:	<Does the patient identify as>	
General Practitioner:	<DrName>	
Does the patient meet criteria?	• Over 65 years of age or 50 years of age for Aboriginal and Torres Strait Islander people and 
• Lives in a community dwelling (including retirement villages) and 
• Experiences a fall (including a slip, trip or stumble) at home or in the community
Not
• Related to chronic alcohol and other drug use
• A fall that occured as an inpatient
• Living in a Residential Aged Care Facility	
Brief history of events:	<Brief history of events>	
Treatment/Action taken:	<Treatment/Action taken>	
Name:	<UsrName>	
Organisation:	<Practice>	
Date:	<TodaysDate>	
Office Use	
Email: WBHHS-ICS-Falls-FC@health.qld.gov.au   &   WBHHS-ICS-Falls-BBH@health.qld.gov.au	
Date received: ........../........../..........	First Contact (date and time): ........../........../..........     ........:.......	
Name:	Designation:	Signature:	

Template: WBHHS_FallService_BP_13-12-22, maintained by CQ,WB,SC PHN - digitalhealth@ourphn.org.au