Skip directly to search Skip directly to A to Z list Skip directly to navigation Skip directly to site content Skip directly to page options
CDC Home

Appendix D-6 Spice Materials

Winchester Falls Project – Structured Secondary Assessment Domains

Question 1 – Basic information

Name:
Address:
GP:
DOB:
Date of assessment:
Date of referral:

Question 2 – Home

House/flat/bungalow/sheltered/RH/NH/independent

Question 3 – Walks

Independent/stick/frame

Question 4 – Carers

Independent/family/carers

Question 5 – Bowels

Independent/continent or continent with help or incontinent occasionally or incontinent or stoma
Continence aids

Question 6 – Bladder

Independent/continent or continent with help or incontinent occasionally or incontinent or catheter
Continence aids

Question 7 – Falls history

How many times has/she or he fallen before this last fall: once/2-5/>5
Has the patient sustained an injury during any fall: yes/no
If yes, which sort:
Head injury: yes/no
Fracture/dislocation: yes/no (please specify)
Laceration requiring medical attention: yes/no
Bruising: yes/no
Others: yes/no (please specify)
Definite slip/trip: yes/no
Loss of consciousness: yes/no
Associated dizziness/palpitations: yes/no
Vertigo: yes/no
Presyncope: yes/no

Question 8 – Drug history

List all medications (including over the counter and prescribed)

Question 9 – Drugs

Is the patient taking any of the following drugs:
Diuretics
Hypnotic/sedative
Antidepressant
Digoxin
Cardiovascular
Anti-parkinsonian

Question 10 – Alcohol consumption

CAGE score
Total number of units/week

Question 11 – Smoking

Do you smoke: yes/no
If yes: cigarettes/pipe/cigars

Question 12 – Past medical history

Heart disease
Stroke/TIA
Respiratory disease
Hypertension
Diabetes
Epilepsy
Parkinson’s disease
Visual problems: wears glasses and last eye check within 2 years
Joint disease
Other neurological disease
Other diseases:

Question 13 – Examination BP

Weight
BP lying
BP standing immediately
BP at 1 minute
BP at 3 minutes

Question 14 – MTS
Question 15 – Vision

Visual acuity with glasses/pin hole:
Right
Left

Question 16 – Pulse
Question 17 – Rhythm
Question 18 – Heart sounds
Question 19 – Cranial nerves

Range of eye movements
Visual fields
Fundi
Pupils
Other findings

Question 20 – Peripheral neurology

Tone (right and left)
Power (right and left)
Reflexes (right and left)
Sensation (right and left)
Cerebellar (right and left)

Question 21 – Chest examination
Question 22 – Abdominal examination
Question 23 – Other findings
Question 24 – Mobility/gait

Aid used and pattern
Pattern
Heel strike
Stance
Stride
Other
Stairs

Question 25 – Joint range and muscle strength

Joint range
Upper limbs
Cervical spine
Lower limbs
Lumbar spine
Muscle strength
Upper limbs
Cervical spine
Lower limbs
Lumbar spine

Question 26 – Getting up from the floor

Pattern: independently/assistance x 1/assistance x 2/unable
Comment:

Question 27 – Transfers

Bed
Chair
Toilet
Bath (reported)

Question 28 – Equipment

Equipment already in situ

Question 29 – Domestic activities of daily living (reported)

Make a hot drink
Prepare a meal
Washing up
Use cooker
Cleaning
Laundry
Shopping
Carrying and lifting

Question 30 – Personal activities of daily living (reported)

Wash and dry self
Dress and undress
Clothes fastenings
Stockings and socks
Shoes and slippers
Personal care

Question 31 – Timed unsupported steady stand

Time in seconds for unsupported/single hand/ double hand stand
Distance between heels

Question 32 – 180 degree turn

Number of steps
Time in seconds

Question 33 – Functional reach

Done standing in dominant arm (measured in inches)

Question 34 – 6 meter timed walk

Time in seconds
Number of steps

Question 35 – Single leg stand

Right leg
Left leg

Question 36 – Clothing and footwear hazards

Clothing
Footwear
Chiropodist: yes/no

Question 37 – Pain

Pain: no pain/ongoing chronic pain/acute and intermittent pain/ongoing and acute
Description

Question 38 – Problem list
Question 39 – Action list
Question 40 – Likely cause of fall

Musculoskeletal
Cardiovascular
Environmental
Medication
Vision
Alcohol
Other
Combination
Comments

Question 41 – Risk factor for falls

Medication
Vision
Alcohol
Postural hypotension
Footwear
Mobility
Medical – neurological
Medical – musculoskeletal
Medical – cardiovascular
Environmental
Other
Combination
Comment

Question 42 – Planned investigations and/or interventions
Question 43 – Follow-up arrangements/referrals
Question 44 – Timings

Doctor:
Physiotherapist:
Nurse:
Occupational therapist:
Other (please specify):

 

Return to top

 

 
Contact Us:
  • Centers for Disease Control and Prevention
    National Center for Injury Prevention and Control (NCIPC)
    4770 Buford Hwy, NE
    MS F-63
    Atlanta, GA 30341-3717
  • 800-CDC-INFO
    (800-232-4636)
    TTY: (888) 232-6348
  • Contact CDC–INFO
USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention   1600 Clifton Road Atlanta, GA 30329-4027, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 - Contact CDC–INFO
A-Z Index
  1. A
  2. B
  3. C
  4. D
  5. E
  6. F
  7. G
  8. H
  9. I
  10. J
  11. K
  12. L
  13. M
  14. N
  15. O
  16. P
  17. Q
  18. R
  19. S
  20. T
  21. U
  22. V
  23. W
  24. X
  25. Y
  26. Z
  27. #