Active Living

This form is to enable health professionals who work with you to find out how you are managing at home, and if you need any help to reduce your risk of falling and getting hurt in the future.

If you are 75 years and older, you can fill in this form. A carer, family member or a health professional can fill in the form with you if you require help.

If the answers you give show that you are at a high risk of falling, the people involved in your care will be able to point you to further advice and support.

Active Living

Section A

Section B

What next?

If you have answered ‘YES’ to any of the questions in Section A or if your total score in Section B is 4 or more, with your consent we may refer you to HertsHelp.

If you answered the questions in this form and:

• you haven’t had any falls in the past year
• you don’t have any problems with getting to the toilet
• you are not experiencing memory problems,
• your total score added up to three or less

Then you are not currently considered to be at a high risk of losing your independence or falling.

See the Health in Herts website - www.hertsdirect.org/healthinherts for advice and tips on staying healthy and active at home or out and about, or visit your local library for information on clubs and healthy activities. If you want to speak to someone about any support needs that you have, call the county-wide advice line ‘HertsHelp’ on 0300 123 4044.

Please note that the details you give will be used to update your medical records. If your correct contact information is not entered we will not be able to respond to you.