Occupational Therapy Assessment Form

Occupational Therapy Assessment Form CLIENT DETAILS - Name: John Doe - Date of initial assessment: 2023-10-15 - Date of birth: 1985-06-20 - Address: 123 Main Street, Springfield - Phone number: (555) 123-4567 - Email address: johndoe@example.com - Next of Kin name and number: Jane Doe, (555) 987-6543 - Persons present during Ax: Jane Doe - Funding body if applicable: Medicare - Medical and health history: History of arthritis and hypertension - Medications: Lisinopril 10mg daily, Ibuprofen 200mg as needed - GP details: Dr. Sarah Smith, (555) 321-7654 - Living Situation: Lives alone in a single-story home - Current community services / social supports and/or allied health input: Weekly physiotherapy sessions - Referrer and reason: Dr. Sarah Smith, referred for assessment of daily living skills For FCA’s: - Level of schooling: Bachelor's degree in Engineering - Employment history: Former mechanical engineer, retired - Social story, family: Widowed, two adult children - Supports that aren't official: Neighbors assist with grocery shopping - NDIS paid for supports: None NDIS INFORMATION - NDIS number: 123456789 - Plan manager contact details: Plan Manager Inc., (555) 654-3210 - Support Coordinator details: Emily Johnson, (555) 432-1098 - Plan dates: 2023-01-01 to 2023-12-31 Other relevant info: - Perceived strengths: Strong problem-solving skills - Things wanting to work on: Improve mobility and balance - Fine and gross motor skills: Difficulty with fine motor tasks, gross motor skills moderately impaired - Sensory needs: No significant sensory needs - What’s something really important to you that you are wanting to do: Travel independently - Sleep: Reports difficulty falling asleep - Social skills/ friends: Active in local community group - Mobility: Uses a cane for walking - Assistive Technology Used: Cane, grab bars in bathroom CLIENT/PARTICIPANT - Reports - Height (Self/carer reported): 175 cm - Weight (Self/carer reported): 80 kg - Hand dominance: Right - Sitting tolerance/balance (Observed): Good - Standing tolerance & static balance (Observed): Fair - Walking tolerance & dynamic balance (Observed): Limited to 100 meters - Sit to stand transfers / other transfers (Observed): Requires minimal assistance - Car transfer: Independent - Current Assistive technology in use (Self/carer reported + observed): Cane, grab bars - Number of falls in last 6 months (Self/carer reported): 2 - Vision (Self/carer reported): Wears glasses - Hearing (Self/carer reported): Normal - Cognitive capacity (Self/carer reported + observed + Ax): Intact - Pressure injury or ulcer history (Self/carer reported): None - Oedema issues (Self/carer reported + observed): Mild in lower extremities - Recent hospitalisations in last month: None - Upper limb function (Observed): Adequate - Sensory issues or concerns (Self/carer reported): None - Communication issues (Self/carer reported + observed): None - Behavioural issues (Self/carer reported + observed): None - Leisure activities/previous occupation: Enjoys gardening, former engineer - Informal supports (Self/carer reported): Neighbors - Community access (Self/carer reported): Limited due to mobility - Received previous OT input/assessment?: Yes, last year HOME - Type of home: Single-story house - Main entry when entering/leaving home: Front door with ramp - Topography of block: Flat - Presentation of property: Well-maintained - Living situation: Lives alone - Time at current property: 10 years - Ownership of home: Owned - Landlord details if applicable: N/A Pre-trial powered mobility device (PMD) questionnaire: - 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?: 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?: Uneven surfaces, low-hanging branches, and narrow pathways - How can you make yourself visible to other pedestrians and drivers?: "Flag, coloured clothing, lighting" Self-care Activities: - Undressing/dressing: Self-reported, Minimum Assistance - Showering/drying: Self-reported, Moderate Assistance - Grooming: Self-reported, Independent - Feeding: Self-reported, Independent - Toileting: Self-reported, Independent Daily Living Skills: - Meal prep & cooking: Self-reported, Shares task with others/some assistance required - Making cup of coffee/tea: Self-reported, Independent - Dish washing: Self-reported, Shares task with others/some assistance required - Cleaning: Self-reported, Dependent - Grocery shopping: Self-reported, Dependent - Making/stripping bed: Self-reported, Shares task with others/some assistance required - Laundry: Self-reported, Shares task with others/some assistance required - Ironing: Self-reported, Dependent - Financial management: Self-reported, Independent - Medication management: Self-reported, Independent - Letterbox and mail management: Self-reported, Independent - Wheelie bins and rubbish management: Self-reported, Shares task with others/some assistance required - Pet care: Self-reported, Independent - Lawn and garden maintenance: Self-reported, Dependent - Managing needs of children: N/A - Phone use / appt making: Self-reported, Independent - Driving / Public transport: Self-reported, Dependent CLIENT GOALS: - Improve mobility and balance - Increase independence in daily living activities - Enhance social participation PROGRESS NOTES: - Client has shown improvement in balance with the use of a cane - Participating in weekly physiotherapy sessions - Engaging in community activities with assistance