Record Identifier: ___________________		Arrival Month: ___________________
Arrival Day: _______________________		Arrival Year: _______________________
Arrival Time: _______________(hh/mm)		Discharge Time: _____________(hh/mm)
Note: 00:00 = Time Missing00:01 = Actual time 00:00		Note: 00:00 = Time Missing00:01 = Actual time 00:00
Age: ____________		Sex: 1 = Male 2 = Female
Within catchment? 1 = Yes 2 = No 3 = Not documented		English speaking: 1 = Yes 2 = No 3 = Not documented
Section 1: Presenting Fall History
Fall description / activity being performed when fall occurred:	1 = Ladder 2 = Fell on ice 3 = Fell out of bed 4 = Tripped on curb/sidewalk/road	5 = Syncope / dizzy 6 = Tripped on other object(s) 7 = Unexplained fall 8 = Other
Fall location:	1 = Bedroom	5 = Living room	9 = Not documented
	2 = Bathroom	6 = Stairs
	3 = Hallway	7 = Outside home
	4 = Kitchen	8 = Other
Time fall occurred:	1 = Day: 06:00–18:00 2 = Night: 18:00–06:00 3 = Not documented
Sequelae / diagnosis:	1 = Laceration 2 = Upper extremity fracture 3 = Lower extremity fracture 4 = Trunk fracture (pelvis, ribs, spine) 5 = Head injury	6 = Soft tissue injury 7 = No diagnosed injury 8 = Other 9 = Multiple site fracture
Was there a loss of consciousness?	1 = Yes 2 = No	3 = Not documented 4 = Unknown
Was the person under the influence of alcohol at the time of the fall?	1 = Yes 2 = No	3 = Not documented 4 = Unknown
What members of the medical team played a role in the screening/ assessment of the patient?	1 = MD and/or RN 2 = MD and/or RN & SW 3 = MD and/or RN & OT 4 = MD and/or RN & OT & SW	5 = MD and/or RN & Other 6 = MD and/or RN & SW & PT
Did the patient see a physiotherapist?	1 = Yes 2 = No or Not Documented
MD = Medical Doctor; RN = Registered Nurse; SW = Social Worker; OT = Occupational Therapist; PT = Physiotherapist
Section 2: Past Medical History
Co-morbidities:
Diabetes?	1 = Yes	2 = No
Cardiovascular disease?	1 = Yes	2 = No
Incontinence?	1 = Yes	2 = No
Osteoarthritis?	1 = Yes	2 = No
Depression?	1 = Yes	2 = No
Cancer?	1 = Yes	2 = No
Stroke?	1 = Yes	2 = No
Neurological condition (e.g., Parkinson's, traumatic brain injury)	1 = Yes	2 = No
Osteoporosis?	1 = Yes	2 = No
Respiratory illness?	1 = Yes	2 = No
Hypo/hyperthyroidism	1 = Yes	2 = No
Dementia (e.g., Alzheimer's, etc.)	1 = Yes	2 = No
Visual	1 = Yes	2 = No
None or not documented	1 = Yes	2 = No
Other	1 = Yes	2 = No
Previous fracture?	1 = In the last month 2 = 1–3 months ago 3 = 3–6 months ago	4 = 7–12 months 5 = Over 1 year 6 = No previous fracture documented
Previous surgery?	1 = In the last month 2 = 1–3 months ago 3 = 3–6 months ago	4 = 7–12 months ago 5 = Over 1 year documented 6 = No previous surgery
# of medications
4 or more medications?	1 = Yes	2 = No
Section 3: Psychosocial
Marital status:	1 = Married 2 = Single 3 = Widowed	4 = Divorced 5 = Not documented
Home supports:	1 = Yes        2 = No	3 = Not Documented
Housing:	1 = House 2 = Condo 3 = Apartment 4 = Nursing home	5 = Retirement home / community assisted 6 = Other 7 = Not documented
Use of stairs in the home?	1 = Yes        2 = No	3 = Not documented
Use of ambulation aids pre-admission?	1 = Yes        2 = No	3 = Not asked or indicated in chart
Type of ambulation aid	1 = Cane 2 = Walker 3 = Wheelchair (incl. scooter) 4 = Crutches	5 = Non-traditional gait aid (e.g., broom, bucket) 6 = Not documented 7 = Multiple aids 81 = Not applicable
Where used?	1 = Inside the home 2 = Outside the home 3 = Both inside and outside the home	4 = Not documented 81 = Not applicable
Was there a referral for ambulation aids at discharge?	1 = Yes 2 = No 3 = Not asked or indicated in chart
Discharge ambulation type	1 = Cane 2 = Walker 3 = Wheelchair / Scooter4 = Crutches	5 = Non-traditional gait aid (e.g., broom) 6 = Not documented 81 = Not applicable
Admitted to hospital?	1 = Yes 2 = No
Section 4: Admission Data
Admit day	(81 = Not applicable)
Admit month	(81 = Not applicable)
Admit year	(81 = Not applicable)
Reason for admission:	1 = Hospitalization due to injury 2 = Hospitalization for other reasons 3 = Failure to cope 81 = Not applicable
Complications during admission?	1 = Yes        2 = No	(81 = Not applicable)
Total length of stay (# days):	0 = < 24 hours
Section 5: Management and Patient Outcomes
Previous history of falls?	1 = Yes 2 = No 3 = Not asked or indicated in chart
Falls risk assessment conducted?	1 = Yes 2 = No
Falls risk assessment score:	81 = Not Applicable If applicable, enter score ________.
Seen by physiotherapist?	1 = Yes 2 = No
Seen by occupational therapist?	1 = Yes 2 = No
Seen by social worker?	1 = Yes 2 = No
Seen by speech language pathologist?	1 = Yes 2 = No
Seen by other allied health professional?	1 = Yes 2 = No
Not seen by other allied health professional?	1 = Yes 2 = No
Referral to family doctor?	1 = Yes 2 = No
Referral to physiotherapist?	1 = Yes 2 = No
Referral to occupational therapist?	1 = Yes 2 = No
Referral to specialty clinic	1 = Yes 2 = No
Referral to rehabilitation hospital?	1 = Yes 2 = No
Referral to other (includes homecare)	1 = Yes 2 = No
No referral documented	1 = Yes 2 = No
Previously presented or admitted for a fall within last 6 months?	0 = 0 or not documented 1 = Once 2 = 2×	3 = 3× 4 = 4× or more
Subsequently presented or admitted due to a fall in the 6 months following?	0 = 0 or not documented 1 = Once 2 = 2×	3 = 3× 4 = 4×
Previously presented or admitted in the last 6 months for a reason other than a fall	0 = 0 or not documented 1 = Once 2 = 2×	3 = 3× 4 = 4
Subsequently presented or admitted in the last 6 months for a reason other than a fall	0 = 0 or not documented 1 = Once 2 = 2×	3 = 3× 4 = 4×
Section 6: Abilities
Gait assessed?	1 = Yes 2 = No
Balance assessed?	1 = Yes 2 = No
Lower extremity range of motion assessed?	1 = Yes 2 = No
Strength assessed?	1 = Yes 2 = No
Cognition assessed?	1 = Yes 2 = No
Vision assessed?	1 = Yes 2 = No
Activities of daily living assessed?	1 = Yes 2 = No
Use of 4 or more medications?	1 = Yes 2 = No
No risk factors assessed	1 = Yes 2 = No

Note : Any missing variables throughout the data collection template should be coded MV = 9, 99, 999