NDIS Initial template

Recognised Disability, Other Conditions & Current Health: - The patient has a history of cerebral palsy and underwent corrective surgery for scoliosis at age 12. - Currently, the patient experiences muscle stiffness and difficulty with fine motor skills, which have been present since childhood. - The patient has a stable mental health status with no history of psychiatric disorders. - The patient has no history of substance use, drug, or alcohol abuse. - The patient has not been hospitalized in the past five years. Medication Management: - The patient is on Baclofen for muscle spasticity. - Medication is administered orally, stored in a secure location, and prescriptions are managed by the primary care physician. Social History and Supports: - The patient lives with their parents. - The patient receives support from family members daily and attends a community support group weekly. - The patient has no forensics history or legal proceedings. Education and Employment: - The patient completed high school with special education support. - The patient is currently unemployed but volunteers at a local community center. Cognition: - The patient demonstrates average cognitive function with no significant deficits. Communication: - The patient communicates effectively using both verbal and non-verbal cues. Mobility: - Indoors, the patient uses a walker and requires minimal assistance. - Outdoors, the patient uses a wheelchair and requires assistance for longer distances. - The patient has a history of falls, primarily due to muscle weakness. Transfers: - The patient requires assistance for bed transfers using a transfer board. - Chair transfers are performed independently with the use of a grab bar. - The patient requires assistance for shower transfers using a shower chair. - Toilet transfers are performed independently with the use of a raised toilet seat. - Car transfers require assistance from a caregiver. Personal Activities of Daily Living: - The patient requires assistance for showering and uses a handheld showerhead. - Dressing is performed independently with the use of adaptive clothing. - The patient requires assistance for grooming tasks such as brushing hair and teeth. - The patient feeds themselves independently but uses adaptive utensils. - The patient has a regular sleep pattern and uses a body pillow for support. Instrumental Activities of Daily Living: - The patient requires assistance for meal planning and uses a meal delivery service. - Meal preparation is performed with assistance from family members. - The patient requires assistance for grocery shopping and uses a shopping list app. - Laundry tasks are performed with assistance from family members. - The patient requires assistance for domestic cleaning tasks. - The patient manages finances with assistance from a family member. Home Environment: - The patient lives in a single-story home owned by their parents. - The home has three bedrooms and two bathrooms. - The living area is accessible with the use of a walker. - The bedroom area is accessible with the use of a walker. - The bathroom and toilet area are accessible with the use of grab bars. - The kitchen area is accessible with the use of a walker. Goals: - The patient's goal is to improve independence in daily living activities. - Occupational therapy recommendations include increasing participation in community activities. - The proposed intervention plan includes weekly therapy sessions for six months. - Referrals to a physiotherapist for additional support have been made.