Occupational Therapy Assessment Form
| CLIENT INFORMATION | |||
| Name | |||
| Programme | |||
| Assessment Date | |||
| Referral Reason | |||
| People Present | |||
| MEDICAL BACKGROUND | |||
| Medical history | |||
| SOCIAL BACKGROUND | |||
| Living Arrangements | |||
| Residence | |||
| Informal Supports | |||
| Formal Support | |||
| SENSORY-MOTOR-COGNITION | |||
| Vision impairment | |||
| Hearing impairment | |||
| Dominant Side | |||
| Limb(s) Affected | |||
| Gross Motor | |||
| Fine Motor | |||
| Pain / Discomfort | |||
| Sensation | |||
| Cognitive Issue | |||
| MOBILITY | |||
| Item | Level | Details | Recommendations |
|---|---|---|---|
| Indoor | |||
| Outdoor | |||
| Community | |||
| Last Fall | |||
| Fall past six months | |||
| Personal Alarm | Confirm client does not have a pacemaker Inform ongoing service fee | ||
| Chair Transfers | |||
| Bed Transfers | Explaine potential risks associated with using a bed pole Provide information sheet | ||
| Toilet Transfers | |||
| Car Transfers | |||
| ACTIVITIES | |||
| Medication Mx | |||
| Eating | |||
| Toileting | |||
| Continence | |||
| Footcare | |||
| Bathing | |||
| Upper/Lower Limb Dressing | |||
| Cleaning | |||
| Laundry Task | |||
| Meal Preparation | |||
| Shopping | |||
| Transport | |||
| Finance/Bill Paying | |||
| Gardening/Bins | |||
| Interests | |||
| HOME ENVIRONMENT | |||
| Front Access | |||
| Side Access | |||
| Rear Access | |||
| Internal Access | |||
| Bathroom | |||
| Toilet | |||
| Bedroom | Potential risks associated with using a bed pole were explained and information was provided. Client agreed to ensure the Mighty Rail remains in place and will inform staff or OT if it moves. | ||
| Laundry | |||
| SUMMARY / RECOMMENDATIONS | |||
| Clients Identified Issue / Difficulty | |||
| Clients Goals | |||
Therapy recommendations | |||
Alaya Form
Information
Social
Sensory
Instrumental Activities of Daily Living (IADLs)
Functional Assessment
Transfers
Personal Activities of Daily Living (PADLs)
Home Environment
Upper Limb Function
Cognitive Impairment
Summary / Recommendations
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Equipment Trial
| TRIAL DETAILS | |||
| Date | |||
| Location | |||
| Item Borrowed From | |||
| Client Name | |||
| Family / Support Present | |||
| Reason for Trial | |||
| Items Trialled | |||
| OBSERVATIONS | |||
| Demonstration Summary | |||
| Client Practice Summary | |||
| SAFETY & PLAN | |||
| Safety Considerations | |||
| Additional Notes | |||
Equipment notes are not saved. Copy the notes to avoid loss.
Client Management
| Date | Program | Client Name | Recommendations | To-Do List |
|---|---|---|---|---|
| No entries saved. | ||||
Data is stored in your device's browser storage and may be lost or damaged due to unexpected errors. Do not store important information. Export and back up your data as needed. Importing data will overwrite entries with the same name.
Notes
Notes stay in your device's browser storage and are not shared. Information may be lost or damaged from unexpected errors. Do not use it to store important data. Export and back up your data as needed. Importing data will replace all existing entries.
Travel Log
| Date | From address | To address | Distance (km) |
|---|
Travel distance estimates require external online services that are not available on the organisation's devices. The calculated distance is not the same as the actual distance driven.
Information may be lost or damaged from unexpected errors. Export and back up your data as needed. Importing data will replace all existing entries.