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General Information

Patient Name*
Patient Date of Birth*
Patient Gender*
Patient Address*
Emergency Contact Person
Patient Physician

Medical History

Onset Date
Prior OT Services Received
When
fahrenheit
/min
e.g. 120/80
Frequency, Causes, Etc.
Sensory Assessment
Sensory Assessment
  Within Normal Limits Within Functional Limits Impared
Vision
Hearing
Tactile

Musculoskeletal Assessment

Left Shoulder ROM
Right Shoulder ROM
Left Shoulder Muscle Strength
Right Shoulder Muscle Strength
Left Elbow ROM
Left Shoulder ROM - Copy - Copy - Copy - Copy - Copy - Copy
Left Elbow Muscle Strength
Right Elbow ROM - Copy
Left Wrist ROM
Right Wrist ROM
Left Wrist Muscle Strength
Right Wrist Muscle Strength
Muscle Tone
Sitting Balance Impairment
Standing Balance Impairment

Functional Independence Measure (FIM) Scale

Functional Activities
Functional Activities
  7 - Ind 6 - Mod I 5 - S S/U 4 - Min 3 - Mod 2 - Max 1 - Total N/A
Feeding
Bathing
Grooming
Upper Dress
Lower Dress
Toileting
Meal Prep
Homemaking
Functional Mobility
Functional Mobility
  7 - Ind 6 - Mod I 5 - S S/U 4 - Min 3 - Mod 2 - Max 1 - Total N/A
Supine to sit
Sit to stand
Bed to chair
Toilet/BSC
Bathtub/Shower
Home Bound Status
Current Functional Problem, Functional Goals

Treatment

Planned Interventions
Communication of care with
Re:
Plan of care discussed with patient/caregiver
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Therapist Name
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Physician Name
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