Occupational Therapy Assessment Form

Occupational Therapy Assessment Form CLIENT DETAILS - Name: [Client's full name] (enter the client's name here) - Date of initial assessment: [Date of assessment] (enter the date of the initial assessment) - Date of birth: [Client's date of birth] (enter the client's date of birth) - Address: [Client's address] (enter the client's address) - Phone number: [Client's phone number] (enter the client's phone number) - Email address: [Client's email address] (enter the client's email address) - Next of Kin name and number: [Next of Kin details] (enter the name and contact number of the next of kin) - Persons present during Ax: [Names of persons present] (list any persons present during the assessment) - Funding body if applicable: [Funding body] (mention funding body details if applicable) - Medical and health history: [Medical history] (include relevant medical and health history) - Medications: [List medications] (include medications with doses, frequency, etc.) - GP details: [GP's name and contact details] (enter GP details) - Living Situation: [Living situation details] (describe the client's living situation) - Current community services / social supports and/or allied health input: [Community services] (list any current services or supports) - Referrer and reason: [Referrer details] (mention referrer details and reason for referral) For FCA’s: - Level of schooling: [Level of schooling] (describe the client's level of education) - Employment history: [Employment history] (mention the client's employment background) - Social story, family: [Social and family history] (provide relevant social and family history) - Supports that aren't official: [Informal supports] (list any informal supports not officially documented) - NDIS paid for supports: [NDIS supports] (describe NDIS-paid supports if applicable) NDIS INFORMATION - NDIS number: [NDIS number] (enter the client's NDIS number) - Plan manager contact details: [Plan manager contact] (provide plan manager contact information) - Support Coordinator details: [Support Coordinator] (mention Support Coordinator's details) - Plan dates: [Plan dates] (enter the start and end dates of the NDIS plan) Other relevant info: - Perceived strengths: [Client's strengths] (list perceived strengths of the client) - Things wanting to work on: [Areas of improvement] (mention things the client wants to work on) - Fine and gross motor skills: [Motor skills] (describe fine and gross motor skills) - Sensory needs: [Sensory needs] (detail any sensory needs) - What’s something really important to you that you are wanting to do: [Important goals] (identify key goals important to the client) - Sleep: [Sleep patterns] (mention sleep patterns or issues) - Social skills/ friends: [Social skills] (describe social skills and friendships) - Mobility: [Mobility status] (detail mobility capabilities and limitations) - Assistive Technology Used: [Assistive technology] (list assistive technologies used) CLIENT/PARTICIPANT - Reports - Height (Self/carer reported): [Height] (enter the reported height) - Weight (Self/carer reported): [Weight] (enter the reported weight) - Hand dominance: [Hand dominance] (state left or right hand dominance) - Sitting tolerance/balance (Observed): [Sitting tolerance] (describe observed sitting tolerance and balance) - Standing tolerance & static balance (Observed): [Standing tolerance] (state observed standing tolerance and balance) - Walking tolerance & dynamic balance (Observed): [Walking tolerance] (describe walking and dynamic balance) - Sit to stand transfers / other transfers (Observed): [Transfer ability] (mention observed transfers) - Car transfer: [Car transfer] (describe car transfer abilities) - Current Assistive technology in use (Self/carer reported + observed): [Assistive tech in use] (list current assistive technologies observed and reported) - Number of falls in last 6 months (Self/carer reported): [Falls] (mention any falls reported) - Vision (Self/carer reported): [Vision] (state vision capabilities) - Hearing (Self/carer reported): [Hearing] (mention hearing status) - Cognitive capacity (Self/carer reported + observed + Ax): [Cognitive capacity] (detail cognitive status observed and reported) - Pressure injury or ulcer history (Self/carer reported): [Pressure injuries] (mention any history of pressure injuries) - Oedema issues (Self/carer reported + observed): [Oedema] (state oedema concerns) - Recent hospitalisations in last month: [Recent hospitalisations] (list any recent hospital admissions) - Upper limb function (Observed): [Upper limb function] (describe upper limb abilities observed) - Sensory issues or concerns (Self/carer reported): [Sensory issues] (mention any sensory concerns) - Communication issues (Self/carer reported + observed): [Communication issues] (detail communication challenges) - Behavioural issues (Self/carer reported + observed): [Behavioural issues] (mention any observed and reported behavioural issues) - Leisure activities/previous occupation: [Leisure and occupation] (detail previous activities or occupations) - Informal supports (Self/carer reported): [Informal supports] (list any informal supports reported) - Community access (Self/carer reported): [Community access] (describe community engagement) - Received previous OT input/assessment?: [Previous OT input] (mention if any previous OT assessments occurred) HOME - Type of home: [Type of home] (state the type of home the client lives in) - Main entry when entering/leaving home: [Main entry] (describe the main entryway) - Topography of block: [Topography] (mention any relevant topography) - Presentation of property: [Property presentation] (state how the property is presented) - Living situation: [Living situation] (describe the client's current living arrangement) - Time at current property: [Time at property] (mention how long the client has been at the property) - Ownership of home: [Home ownership] (state ownership details) - Landlord details if applicable: [Landlord details] (provide details if relevant) Pre-trial powered mobility device (PMD) questionnaire (include only if relevant): - Are PMD users considered motorists or pedestrians?: "Pedestrian" - At what speed should a PMD be driven?: "Maximum speed 10km p/hr" - Where should a PMD be used or driven?: "Devices should be driven on the footpath with travel on the road only permitted if a suitable footpath is unavailable" - What position on the footpath should a PMD maintain?: "They must keep to the left and give way to other pedestrians." - If you have to travel on the road, should you be facing the traffic, or should it be behind you?: "If there is no footpath or nature strip, walk so you’re facing oncoming traffic." - When approaching a road, what are three things you will need to consider before crossing?: [Considerations for crossing] (state oncoming traffic, speed, and curb height) - In what position should the PMD be, prior to crossing kerb?: "Straight on/facing curb" - Can you identify three potential problems or obstacles you may face on a footpath?: [Identify potential problems] (list any potential obstacles) - How can you make yourself visible to other pedestrians and drivers?: "Flag, coloured clothing, lighting" Self-care Activities: - Undressing/dressing: [Self/carer reported, level of assistance] - Showering/drying: [Self/carer reported, level of assistance] - Grooming: [Self/carer reported, level of assistance] - Feeding: [Self/carer reported, level of assistance] - Toileting: [Self/carer reported, level of assistance] (For each item in the above section, mention whether self reported or carer reported and choose one of the following levels of assistance: Independent, Minimum Assistance, Moderate Assistance, Maximum Assistance, Dependent) Daily Living Skills: - Meal prep & cooking: [Self/carer reported, level of assistance (e.g., Independent, Shares task with others/some assistance required, Dependent)] - Making cup of coffee/tea: [Self/carer reported, level of assistance (e.g., Independent, Shares task with others/some assistance required, Dependent)] - Dish washing: [Self/carer reported, level of assistance] - Cleaning: [Self/carer reported, level of assistance] - Grocery shopping: [Self/carer reported, level of assistance] - Making/stripping bed: [Self/carer reported, level of assistance] - Laundry: [Self/carer reported, level of assistance] - Ironing: [Self/carer reported, level of assistance] - Financial management: [Self/carer reported, level of assistance] - Medication management: [Self/carer reported, level of assistance] - Letterbox and mail management: [Self/carer reported, level of assistance] - Wheelie bins and rubbish management: [Self/carer reported, level of assistance] - Pet care: [Self/carer reported, level of assistance] - Lawn and garden maintenance: [Self/carer reported, level of assistance] - Managing needs of children: [Self/carer reported, level of assistance] - Phone use / appt making: [Self/carer reported, level of assistance] - Driving / Public transport: [Self/carer reported, level of assistance] (For each item in the above section, mention whether self reported or carer reported and choose one of the following levels of assistance: Independent, Shares task with others/some assistance required, Dependent) CLIENT GOALS: - [Client's goals] (list specific goals the client wishes to achieve) PROGRESS NOTES: - [Progress notes] (document progress notes as relevant) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)(Use as many bullet points as needed to capture all the relevant information from the transcript.)