Occupational Therapy Assessment for Spinal cord injury

Date:
Name: Age: Diagnosis and level:
(Complete / incomplete)

Family situation :

Educational status
Vocational status

Emotional status :

Personal Hygiene:

Complications: Pressure sore, Spast+city, Orthostatic hypotension, autonomic dys

reflexia, UTI (if any, describe )

MOBILITIY
Bed mobility: FIM Score
Turning to sides
Supine Prone
Indoor mobility: w/c, crutch, walker, bottom shuffling
Outdoor mobility: tricycle, w/e, modified two wheeler, car & auto.

Wheel Chair/Crutch/Walker Transfer FIM Scale

Wheel chair/Crutch Bed
Wheel chair / Crutch +Toilet stool
Wheel chair/Crutch Floor
Wheel chair/ Crutch Car, Auto, Bus, Train

Pivot Transfer
Direct Transfer
Floor Transfer
 Home Evaluation:
Rental house/Own house
Ground/ First / Second Floor
No of steps (mention the
place)
No of threshold (mention the
place)

Door width Accessible / Inaccessible

Hall
Room
Kitchen
Toilet & Bathroom

Toilet
Common / Individual toilet
Indian/Western (mention if raised from floor) Accessible/ inaccessible
Modified toilet Y/N (if yes, describe)

Kitchen Accessible / inaccessible

Working platform
Shelf
Inside space
Switch board
Wash basin

Bladder Management ICC/DC/Condom/Suprapubic catheter/Voluntary

(Self/ others)

Bowel Management DE/Suppositories/Voluntary

(Self/ others)

Activities of Daily Living FIM Scale

Bathing Upper body

Lower body
Dressing Upper body
Lower body
Cooking
Bowel management
Bladder management
Menstrual management
Wheel chair maintenance (including
cushion):
Wheelchair Height
Width
Depth
Has appropriate wheelchair
YN
Has appropriate cushion YIN

Wheel chair maneuver:

Able to propel self YN
Able to overcome curbs &
ramp Y/N

Wearing caliper FIM Score

Balance
In sitting / standing Able to maintain both hand on space
Chest level
Shoulder level
Over head

Level of stooping in high sitting

Level of stooping in long leg sitting -

Play &Leisure;

Prolems Identified

Short Term Goals: