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Enhanced care
Free exercise & falls prevention classes
Community Step Up program
1-877-696-1620
1-604-244-2057 (BC)
[email protected]
Community Step Up program form
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Referral information
Referral date
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Contact name
*
Email
*
Organization name
*
Contact number
*
Client/SDM approved referral
*
Y
N
Client information
Client name
*
DOB
*
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Contact number
*
Street address
*
Postal code
*
Gender
*
Male
Female
Email
City
*
Language
*
If required: substitute decision maker information
SDM name
Alternate number
Street address
Same as client address
Other address
Postal code
Day time number
Same as client contact number
Day time other
Email
City
Preferred language
Medical information
Primary care physician
*
Phone number
*
Fax number
*
Overall health concerns
Balance
Strength
Range of motion
Gait/Ambulation
Acute Injury/event (sprain, fracture, cardiac, neuro)
Post-operative
High risk for falls / post fall
Pain
Needs support with ADLs
Fine motor skills
Home safety
Coughing while eating or taking longer to eat meals
Making modification to their foods or avoiding certain foods
History of acid reflux
Gradual or sudden change in their communication
Difficulty understanding what the client is saying (not related to ESL)
Difficulty finding their words
Overall health concerns:
Chronic conditions
Alzheimer's/Dementia
Asthma
Cardiac
Diabetes
Stroke
Other
Arthritis
Cancer
COPD
Neurological (ALS, MS, Parkinson's)
Shortness of breath
Chronic conditions:
Considerations for the program
Does the client suffer with incontinence?
*
Yes
No
Does the client need assistance with toileting?
*
Yes
No
Does that the client have responsive behaviours?
*
Yes
No
If the client has responsive behaviours to what level?
*
Does the client have impulsivity?
*
Yes
No
If the client has impulsive behaviour to what level?
*
Is there any history of violence?
*
Yes
No
Explain
*
Other concerns
*
Leave this field blank
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