<p>OCCUPATIONAL THERAPY INITIAL EVALUATION RE-EVALUATION DISCHARGE MD ORDER AGENCY: ______PATIENT NAME: ______DOB: ______HIC#______Medical diagnosis: Primary: ______Secondary: ______</p><p>Medical history: ______Onset date: ______</p><p>PMH: ______</p><p>Condition prior to onset: ______Precautions: ______Mental status: alert + oriented x 1 2 3 frequently confused Homebound status: needs assist with transfers gait leaving the home unable to be up for a long period. Cognitive Skills attention span _____% problem solving _____% safety judgment UE Function ROM STRENGTH _____% motivation _____% follows directions _____% frustration R L R L _____% Shoulder flexion short term memory _____% long term memory _____% extension Deficits Visual perceptual Yes/No Sensory Yes/No Aphasia Yes/No expressive receptive abduction Dysphasia Yes/No Special diet Yes/No internal rot. Gross motor control ______Fine motor control ______Tone ______Endurance external rot. ______Elbow flexion Pain Yes/No Location ______extension Aggravated by ______Level ______on a scale of 10 Forearm pronation Functional Activities RIGHT LEFT supination Bed mobility: Rolling _____ % assist _____ % assist Wrist flexion Supine to sit _____ % assist _____ % assist Sit to stand _____ % assist _____ % assist extension Transfers: Sitting pivot Yes/No Standing Pivot Yes/No ulnar dev. WC _____ % assist Bed _____ % assist Tub/shower _____ % assist radial dev. Assistive device Yes/No Specify: ______Sitting balance: Static _____ % assist WB UE Yes/No Dynamic _____ % assist WB UE Fingers flexion Yes/No extension Standing balance: Static _____ % assist device Yes/No Dynamic ____% assist Specify: opposition ______DME : WC mobility _____% assist WC management _____ % assist Activities of Daily Living Feeding: _____ % assist Grooming: _____ % assist UE dressing: _____ % assist Hygiene: _____ % assist LE dressing: _____ % assist DME needs: Toileting; _____ % assist Bathing: _____ % assist Home Management Skills Home/Safety Meal Prep.: _____ % assist Home accessibility: _____ % assist Home making: _____% assist TREATMENT PLAN TREATMENT CODES (circle) 1. ______D1 Evaluation D2 ADL training 2. ______D3 Muscle reed D4 Therap. Ex 3. ______D5 Balance act D6 Muscle reed. 4. ______D7 Neuro-develop. 5. ______D8 Energy conservervation D9 Orthotics/splinting D10 Functional mobility training D11 Other GOALS Short Term Time frame GOALS Long Term Time frame 1. ______1. ______2. ______2. ______3. ______3. ______4. ______4. ______5. ______5. ______</p><p>Frequency: ______x wks for ______wks f/b ______x wks for ______wks Rehab. Potential: ______Prognosis: ______Therapist name: ______Signature: ______Date: ______</p><p>Physician name: ______Signature: ______Date: ______</p><p>Verbal approval: Physician Date: ______Agency Date: ______Theramax FAX: (713) 244-9506 Risty Durbin, PT 3/1/06</p>