Fall Prevention Clearinghouse Registration

Fill out this form to be mailed a packet of information tailored for you, to help you identify and address fall risks.

* Required









I have never fallen and am interested in taking preventive steps
I have fallen once in the past year
I have fallen more than one time in the past year
I have fallen in previous years but not recently
I have a fear of falling
I am the loved one of a senior at risk of falling

61-70
71-80
81-90
90+

Improving balance; addressing dizziness
Fall risk assessment
Increasing strength and endurance
Maintaining independence
Medication management
Assistive devices and their use
Disease management
Home safety assessment
Overcoming the fear of falling
Home safety modifications
Behavior modification for safety
Tailored prevention plan
Community services - please list below
Other - please explain below


Yes


Acknowledgment of Terms

By entering my name and address and completing the information on this form, I am registering for a free, one-year, fall prevention information service and agree to the conditions contained within this Acknowledgment.

The fall risk and prevention information will be provided to me through the U.S. Postal Service as a public service of Home Therapy of Austin, LLC (Home Therapy). The information will be related to the areas of interest I select on the form and will be sent on an unscheduled basis throughout the year.

Although care has been taken to ensure the accuracy, completeness and reliability of the information provided, Home Therapy assumes no responsibility therefore. In no event shall Home Therapy of Austin, LLC be liable for any direct, indirect, special or incidental damage resulting from, arising out of or in connection with the use of the information.

Home Therapy agrees not to use personal information for the purpose of solicitation nor will the information be sold, rented or otherwise disclosed.Home Therapy of Austin, LLC does not assume responsibility for protection of personal information from a data or internet breach.

There is no personal protected health information shared through the Clearinghouse.

Should you choose to have your name removed from the Clearinghouse or should you have questions or concerns please call 512-637-1550.

ARTICLES

  1. Seniors and Fall Related Concussions Amy Potter 23-Sep-2016