Assessment Details

Occupational Therapy

Initial Assessment

Client Details

Name

Date of Birth

Phone Number

Email Address

Address

Street addressStreet address line 2

Suburb

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Occupational Therapist Details

Name

Position

Phone Number

Email Address

Assessment Details

Date of Assessment

Referral Source

Reason for Referral

Name of Referrer

Referrer's Email Address

Consent Obtained

Yes - VerbalYes - WrittenNo - VerbalNo - Written

Persons Present for AssessmentDaphne Totten - Occupational Therapist

Relevant Medical History

Medication

YesNo

Provide further details

Sedative

YesNo

Provide further details

Vision

ImpairedNormal

Provide further details

Glasses

YesNo

Provide further details

Hearing

ImpairedNormal

Provide further details

Hearing Aids

YesNo

Provide further details

Falls History

Medical Conditions

Body Functions & Structures

Body Functions & Structures

Cognitive Evaluation

Psychosocial Symptoms

Communication

Hearing

Vision

Sensation

Pain

Upper Limb Assessment including fine motor control

Lower Limb Assessment

Pressure Care Needs

Continence

Mobility including indoor mobility and bed mobility (stairs, steps, thresholds, etc.)

Sitting tolerance and seating posture

Transfers

Environments

Environments

Physical Environment

Type of Residence

ApartmentBungalowDuplexGranny FlatHouseTerraceTownhouseUnitOther

Provide further details

Home Ownership

RentalSole Ownership (One person owns the property)Joint Ownership (Two or more people share equal ownership and rights over the property)Other

Provide further details

Who does the client live with?

Summary of the Current Environment, Including Previous Home Modifications, & Assistive Technology

Driveway

Driveway Photo/s

Browse

Front Access

Front Access Photo/s

Browse

Back Access

Back Access Photo/s

Browse

Garage

Garage Photo/s

Browse

Backyard

Backyard Photo/s

Browse

Internal

Internal Photo/s

Browse

Hallway

Hallway Photo/s

Browse

Bathroom/s

Bathroom Photo/s

Browse

Toilet/Powder Room

Toilet/Powder Room Photo/s

Browse

Bedroom/s

Bedroom/s Photo/s

Browse

Living Room/s

Living Room/s Photo/s

Browse

Dining Room/s

Dining Room/s Photo/s

Browse

Kitchen

Kitchen Photo/s

Browse

Laundry

Laundry Photo/s

Browse

Other (please specify)

Other Specified Areas Photo/s

Browse

Social Environment: Supports, Family, & Personal History

Formal Supports via HCP, SAH, or STRC (including cleaning & gardening assistance)

Personal History and Family Support (including family support frequency and sustainability of current arrangements)

Other Supports (including neighbours, charities, and friends)

Activities

Activities

Activities of Daily Living (ADL) Assessment

Personal Hygiene

Grooming & Dressing

Toileting

Medication Management

Eating & Drinking

Instrumental Activities of Daily Living (IADL) Assessment

Meal Preparation

Domestic Tasks

Managing own affairs

Yard & garden maintenance

Phone & use of technology

Community Participation Assessment

Outdoor mobility

Transportation/Community access

Shopping

Leisure activities

Recommendations

Occupational Therapy Recommendations

Put goals in order of priority

Goal

Recommendations

Actions

Occupational Therapist Signature

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Occupational Therapist Name

Date of Occupational Therapist Signing

This is the final copy of the assessment and will be sent to the referrer email address

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