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  • Initial Evaluation Form1

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    aderenne
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    The initial evaluation form collects information on a patient's diagnosis, fall risk, pain level, orientation, prior functional abilities, living situation, home set-up, hand dominance, rehabilitation goals, upper extremity strength and range of motion, functioning in activities of daily living, cognition, mobility, and safety. It also documents whether the patient requires assistance after discharge from therapy.

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    The initial evaluation form collects information on a patient's diagnosis, fall risk, pain level, orientation, prior functional abilities, living situation, home set-up, hand dominance, rehabilitation goals, upper extremity strength and range of motion, functioning in activities of daily living, cognition, mobility, and safety. It also documents whether the patient requires assistance after discharge from therapy.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    14 views1 page

    Initial Evaluation Form1

    Uploaded by

    aderenne
    The initial evaluation form collects information on a patient's diagnosis, fall risk, pain level, orientation, prior functional abilities, living situation, home set-up, hand dominance, rehabilitation goals, upper extremity strength and range of motion, functioning in activities of daily living, cognition, mobility, and safety. It also documents whether the patient requires assistance after discharge from therapy.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 1

    OT Initial Evaluation Form Time: Patient Name: Diagnosis/Condition: Fall Precaution?

    YES NO Precautions: Pain (0-10): Orientation:


    Prior Functional Mobility: Prior Basic ADL: Prior Toileting: Prior Bathing Prior Homemaking: Prior Transportation: Mobility Equipment at Home: ADL Equipment at Home: Marital Status & Children: Work Status & Job Description: Lives with: Type of residence: Main level: Second story: Int/Ext Stairs & Railings: Hand Dominance: Post-D/C Support: Rehab Goals: Upper Extremity Strength Test Shoulder

    Room #:

    Apartment Bedroom Bedroom

    House Toilet Toilet

    Own Shower Shower

    Rent Laundry Laundry

    ALF

    NH

    Elbow Forearm Wrist Finger Upper Extremity Range of Motion Shoulder

    Abd Flex IR Flex Sup Flex Flex Abd Flex IR Flex Sup Flex Flex

    LEFT Add Ext ER Ext Pro Ext Ext LEFT Add Ext ER Ext Pro Ext Ext

    Abd Flex IR Flex Sup Flex Flex Abd Flex IR Flex Sup Flex Flex

    RIGHT Add Ext ER Ext Pro Ext Ext RIGHT Add Ext ER Ext Pro Ext Ext

    Elbow Forearm Wrist Finger

    Functioning in ADLs: Cognition/Vision: Mobility: Safety:

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