NDIS Initial.

Section: Patient Information * Name: John Smith * Date of Birth: 12/03/1960 * Address: 123 Main Street, Anytown * Contact Information: 01234 567890 Emergency contact or guardian: Jane Smith, Wife. Employment/day program status, school involvement, volunteering, or roles at home: Retired. Current NDIS plan dates, funding type, relevant goals: Current NDIS plan active until 12/03/2025. Core and Capacity Building funding. Goals include improving mobility and independence. Section: Primary Diagnosis / Disability Main disability: Cerebral Palsy. Secondary diagnoses or comorbidities: Osteoarthritis. Date of diagnosis and source: Diagnosed with Cerebral Palsy at birth. Section: Medical History * Relevant medical conditions: Cerebral Palsy, Osteoarthritis, Hypertension. * Past surgeries or significant injuries: Right hip replacement (2020). * Current medications: Lisinopril 20mg daily, Paracetamol as needed. * Allergies: None known. Section: Social / Environmental History Living arrangements: Lives at home with his wife. Support system: Wife provides significant support. Also receives support from a home care agency. Cultural or language considerations: English is his first language. Daily routine and engagement in activities: Enjoys gardening and watching television. Section: Mobility and Function Current mobility status: Ambulates with a walking frame. Transfers: Independent transfers with walking frame. Stairs: Requires assistance with stairs. Endurance: Reduced endurance, fatigues easily. Falls history: No falls in the last 6 months. Balance and postural control: Mild postural instability. Functional use of limbs: Reduced use of right upper limb due to spasticity. Section: Communication and Cognition Level of understanding and ability to follow instructions: Good understanding and able to follow instructions. Behavioural considerations or sensory needs: No behavioural considerations. Use of AAC: Not applicable. Section: Pain Presence, location, frequency, triggers, current strategies: Reports occasional pain in right hip, especially after walking. Uses Paracetamol for pain relief. Section: Equipment * Current equipment in use: Walking frame, shower chair. * Suitability of current equipment: Equipment is suitable but requires review. * History of previous trials or rejections: No previous trials or rejections. Section: Home Environment and Accessibility Known barriers in the home environment: Steps at the front and back doors. Previous home modifications or future needs: Ramp required for front door access. Section: Support Team and Allied Health Involvement * Other therapists involved: Occupational Therapist. * Medical specialists or regular GP: GP: Dr. Jane Doe. * Support coordinator or case manager: NDIS Support Coordinator: ABC Support Services. Section: Subjective Reason for physiotherapy referral: Referred for assessment of mobility and falls risk. Patient’s or carer's understanding of condition: Patient understands his condition and its impact on his mobility. Functional concerns: Difficulty with walking and transfers. Prior physiotherapy or rehab experience: Attended physiotherapy following hip replacement. Hopes, expectations, or concerns: Hopes to improve walking ability and reduce falls risk. Section: Patient-Centered Goals * Short-term goals: Improve walking distance, reduce pain. * Long-term goals: Maintain independence with mobility. * Relevant NDIS plan goals: Improve mobility and participation in community activities. Section: Objective Assessment * Observation: Posture: Mild kyphosis. Gait: Slow, shuffling gait with walking frame. Skin integrity: Intact. * ROM and flexibility findings: Reduced hip flexion and extension on the right. * Strength: Functional muscle testing: Reduced strength in lower limbs. * Balance: Static balance: Mildly impaired. Dynamic balance: Impaired. * Mobility tests performed and results: Timed Up and Go test: 25 seconds. * Neurological findings: Mild spasticity in right lower limb. * Fatigue tolerance or exertion response: Moderate fatigue after 10 minutes of walking. Section: Assessment / Clinical Impression Summary of findings: Reduced mobility, balance impairments, and falls risk. Clinical diagnosis or classification: Cerebral Palsy, Osteoarthritis. Impact of disability on participation: Limits participation in community activities. Identified risks: High risk of falls. Section: Plan * Recommended physiotherapy focus: Gait retraining, balance exercises, strengthening exercises. * Frequency and duration of therapy: Twice a week for 6 weeks. * Recommended equipment trial or review: Review walking frame and consider a rollator. * Plan to liaise with support team or case conference: Liaise with Occupational Therapist and NDIS Support Coordinator. * Education topics to address: Falls prevention strategies, home exercise program. * Home exercise program initiation and progression: Commence home exercise program with exercises for strength and balance. * Referral suggestions: Consider referral to a podiatrist for footwear assessment.