Professional Documents
Culture Documents
SUBJECTIVE:
- Functional/independedt
CHIEF COMPLAINT OT ORDERS/ GOALS
-reason for referral (ano sabi ng doctor)
Indicate specific goals from the caregiver (ano yung mga concern)
-indicate summary of check up reports/ school reports
- concerns of parents in relation to OT
- goals of parents in relation to areas of occupational areas and
performance skils
Child’s strenggths and areas of improvement
Pt was born (Full / Pre / Post ) term via ( NSD / CS ) to a GP() ____ y/o mother
Prenatal History
vices during the pregnancy
illnesses or problems encountered
pre-natal check ups were conducted
activities of the mother during the pregnancy
Perinatal History
mode of delivery
hospital
may complications ba?
APGAR score (if recalled)
Birth weight
Newborn screening test/s and results (if any)
Postnatal History
Kalian na noticed signs or symptoms (indicate specific age)
general behavior of the client including the age when specific skills were achieved (e.g. self-help etc)
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What prompted them to consult a doctor? When was consult made? What was the diagnosis?
Doctor’s orders?
Services received prior to evaluation? (OT, SLP, PT, SPED, or any form of intervention).
Routines/Habits:
Pakisabi po ng routines ni ______ and ang kanyang mga habits? Usual na gingawa (bahay, school?)
Play preferences/opportunities:
As observed by the caregiver
If possible, subjective information from the patient/child
Educational History:
Indicate if child is currently attending the school; contextualize (number of students, typical activities, subjects, etc.)
Describe the context (number of rooms; floors/ where does the child spend most of his time; where does he sleep etc)
OBJECTIVE:
Remarks:
SOCIAL PARTICIPATION
EYE CONTACT:
( ) meaningful ( ) fleeting ( ) inconsistent ( ) absent
( ) STRANGER ANXIETY:
( ) SEPARATION ANXIETY:
LEVEL OF SOCIAL INTERACTION ACCORDING TO PARTEN
( ) unoccupied ( ) solitary ( ) onlooker ( ) parallel ( ) associative ( ) cooperative
Remarks:
2
IE_PEDIA_BU
SELF-HELP
Age- Age-
Occupation Description appropriat inappropri Level of Assistance
e ate
Eating/Feeding Picky eater??
Food refusal? Ano ang mga ayaw?
Food rituals?
UBG
Dressing
LBG
Toileting
Bathing
Grooming/Hygiene
Level of independence:
( ) age-appropriate dependence
( ) age-inappropriate dependence
( ) independent
EDUCATION
Describe the age appropriate and relevant activities given to the child
Describe the response of the child
School:
Type:__private, __public
Grade level:
Student ratio:
School placement: mainstream, inclusion, SPED?
Saan nakaupo?
Subjects and usual activities in school?
Current performance of the child
How child behave?
Response:
3
IE_PEDIA_BU
LANGUAGE-COMMUNICATION SKILLS
Speech level:
Number
Alphabet
Positional
Other Cognitive
Skills
( ) Integrated
4
IE_PEDIA_BU
GROSS MOTOR SKILLS
Age- Age
Remarks
appro innapro GMS
priate priate (duration, level of assist, activity)
HEAD CONTROL
pull to sit
prone
sitting
TRUNK CONTROL
rolling over
prone on
elbows
prone on hands
sitting
PELVIC CONTROL
pelvic bridging
quadruped
kneeling
standing
Bilateral Coordination
Eye-Hand
Arm-Hand
Midline Crossing
In-hand Manipulation:
(/) Remarks (Activity and Response of the child)
Finger-to-palm translation
Palm-to-finger translation
Shifting
Simple rotation
Complex rotation
Remarks Remarks
Skill Skill
(quality of movement, activity) (quality of movement, activity)
( ) Running ( ) Throwing
( ) Jumping ( ) Catching
( ) Hopping ( ) Kicking
( ) Stairs &
Climbing
5
IE_PEDIA_BU
( ) Imitative Scribble ( ) Random Snips
( ) Spontaneous Line
Scribble
( ) Cut
Line Curve
( )
Shape Shapes
Tracing
Letter ( ) Cut Pictures/
Line Figures
( ) ( ) Mature Scissor
Shape
Imitation Grasp
Letter
Line ( ) Complex Cutting
( )
Shape
Copying
Letter