Wide Bay Hospital and Health Service
Integrated Care Services
WIDE BAY FALL 
PREVENTION SERVICE
Referral Form
Referral to: <<Referral to: >>	URN: 
Family Name: <<Patient Demographics:Surname>>
Given Name(s): <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>
Address: <<Patient Demographics:Address>>
Date of Birth: <<Patient Demographics:DOB>>
Sex: <<Patient Demographics:Gender>>	
Date: <<Miscellaneous:Date>>          QAS Incident Number: 	
Patient's verbal consent:  <<Patient's verbal consent>> 	
<<Consent>>	
Patient details	
Name:	<<Patient Demographics:Full Name>>	
Address:	<<Patient Demographics:Address>>	
Phone:	Home: <<Patient Demographics:Phone (Home)>>   
Mobile: <<Patient Demographics:Phone (Mobile)>>	
Date of Birth:	<<Patient Demographics:DOB>>	
Gender:	<<Patient Demographics:Gender>>	
Does the patient identify as:	<<Patient Demographics:ATSI>>	
General Practitioner:	<<Doctor:Name>>	
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>>	
Referrer: <<Doctor:Name>>	Provider number: <<Doctor:Provider Number>>	
Organisation: <<Practice:Name>>	Date: <<Miscellaneous:Date>>	
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: 	

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