P.O. BOX 2415 - WCB



0000P.O. BOX 2415EDMONTON, AB T5J 2S5FAX: 780-427-58631-800-661-1993C1258OCCUPATIONAL THERAPY SERVICES Personal Care Allowance and Home Equipment Initial AssessmentWORKER DETAILSWCB Claim Number[Claim#]Surname[Surname]First Name and Initial[FirstName]Date of Birth (yyyy/mm/dd) FORMTEXT ?????Address Street FORMTEXT ?????City/Town FORMTEXT ?????Province FORMTEXT ?????Postal Code FORMTEXT ?????Telephone Number FORMTEXT ?????Referral Date (yyyy/mm/dd) FORMTEXT ?????Assessment Date (yyyy/mm/dd) FORMTEXT ?????Date of Accident (yyyy/mm/dd) FORMTEXT ?????Provider’s Name FORMTEXT ?????Telephone Number FORMTEXT ?????Provider Reference Number FORMTEXT ?????Compensable Conditions (based on referral form) FORMTEXT ?????Non Compensable Conditions Impacting Return to Work (based on referral form) FORMTEXT ?????GENERALReferral Questions FORMTEXT ?????Brief History FORMTEXT ?????Worker’s Height FORMTEXT ????? (inches)Weight FORMTEXT ????? (lbs)Physical and Functional Assessment FORMTEXT ?????LIVING SITUATIONType of Residence FORMCHECKBOX Trailer/Mobile home FORMCHECKBOX Apartment FORMCHECKBOX Town house/Condominium FORMCHECKBOX Bungalow FORMCHECKBOX Split level FORMCHECKBOX Two-story FORMCHECKBOX Other (Specify): FORMTEXT ?????Ownership FORMCHECKBOX Owned FORMCHECKBOX RentedLiving Arrangement FORMCHECKBOX Lives alone FORMCHECKBOX Lives with family/friendSupportDoes the worker receive assistance from family or friend? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe the assistance that he/she receives: FORMTEXT ?????Did they receive this level of assistance prior to them being injured? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, describe what has changed: FORMTEXT ?????Family SituationDo they have children? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how many? FORMTEXT ?????What is/are their age(s)? FORMTEXT ?????Are the children dependent? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, who provides the daily child-care? FORMTEXT ?????MOBILITYIndependentRequires AssistanceDependentStairs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Inside the home FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Outside the home FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX In/out of bed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX In/out of chair/wheelchair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Wheelchair to toilet FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Into shower or bathtub FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX In/out of vehicle FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Describe the assistance required and whether it is due to the work-related injury. FORMTEXT ?????Mobility Aids Currently Using FORMCHECKBOX Cane FORMCHECKBOX Crutches FORMCHECKBOX Walker FORMCHECKBOX WheelchairBOWEL ROUTINEIndependentRequires AssistanceDependentBowel toileting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Continence FORMCHECKBOX All of the time FORMCHECKBOX Some of the time FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX IncontinenceReason FORMCHECKBOX Urgency FORMCHECKBOX Unaware of need to void FORMCHECKBOX Other (Specify): FORMTEXT ?????Bowel Care/Routine FORMCHECKBOX Suppository FORMCHECKBOX Digital stimulation FORMCHECKBOX Other (Specify): FORMTEXT ?????Describe the worker’s bowel routine. FORMTEXT ?????Equipment Used FORMCHECKBOX None FORMCHECKBOX Commode FORMCHECKBOX Raised toilet seat FORMCHECKBOX Toilet frame grab barsOther Information on Bowel Routine FORMTEXT ?????BLADDER ROUTINEIndependentRequires AssistanceDependentBladder toileting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Continence FORMCHECKBOX All of the time FORMCHECKBOX Some of the time FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX IncontinenceReason FORMCHECKBOX Urgency FORMCHECKBOX Unaware of need to void FORMCHECKBOX Other (Specify): FORMTEXT ?????Frequency FORMCHECKBOX Rarely FORMCHECKBOX FrequentlyOccurrence FORMCHECKBOX Any time FORMCHECKBOX Night time onlyBladder Routine FORMCHECKBOX Catherization FORMCHECKBOX Intermittent catherizationDescribe the type and frequency of catherization: FORMTEXT ?????Other Information on Bladder Routine FORMTEXT ?????IndependentRequires AssistanceDependentNot ApplicableMenstrual care FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Assistance required (Specify frequency and time required): FORMTEXT ?????HYGIENE/GROOMING AND SKIN CAREIndependentRequires AssistanceDependentBathing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Primary form of bathing: FORMCHECKBOX Bath FORMCHECKBOX Shower FORMCHECKBOX Bed bathAssistance required (Specify frequency and time required): FORMTEXT ?????Equipment Used FORMCHECKBOX None FORMCHECKBOX Shower chair/stool/commode FORMCHECKBOX Wheel in shower chair FORMCHECKBOX Hand-held shower FORMCHECKBOX Bath bench FORMCHECKBOX Bath lift FORMCHECKBOX Grab barsEquipment Recommended (based on the work-related injury)Check off all applicable aids/equipment FORMCHECKBOX Bath seat/bench FORMCHECKBOX Shower chair/stool/commode FORMCHECKBOX Bath lift FORMCHECKBOX Shower trolleys FORMCHECKBOX Commode FORMCHECKBOX Wheel in shower chair FORMCHECKBOX Raised toilet seat FORMCHECKBOX Grab bars FORMCHECKBOX Toilet arm rests FORMCHECKBOX Hand held shower FORMCHECKBOX Other (Specify): FORMTEXT ?????GroomingIndependentRequires AssistanceDependentBrushing teeth FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Brushing/combing hair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shampooing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shaving FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Applying make-up FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Applying deodorant FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Applying cologne/perfume FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other (Specify): FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Assistance required (Specify frequency and time required): FORMTEXT ?????Skin Care IntegrityIndependentRequires AssistanceDependentChecking skin FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Applying lotions/powder FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comment on tissue or skin integrity issues: FORMTEXT ?????DRESSINGIndependentRequires AssistanceDependentUnderwear FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shirt FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Pants FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Socks FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Dresses (if applicable) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Coats FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shoes/boots FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Zippers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Buttons FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Putting clothes away FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Putting on/removing glasses FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Putting on/removing earrings FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Putting on/removing hearing aids FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Equipment Used FORMCHECKBOX None FORMCHECKBOX Button hook FORMCHECKBOX Zipper puller FORMCHECKBOX Sock aid FORMCHECKBOX Other (Specify): FORMTEXT ?????Equipment Recommended (based on the work-related injury) FORMCHECKBOX None FORMCHECKBOX Button hook FORMCHECKBOX Zipper puller FORMCHECKBOX Sock aid FORMCHECKBOX Long handle shoe horn FORMCHECKBOX Other (Specify): FORMTEXT ?????Assistance required (Specify frequency and time required): FORMTEXT ?????NUTRITIONIndependentRequires AssistanceDependentPreparation of simple meals FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Preparation of main meals FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Eating FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Drinking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Meal clean-up FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Equipment Used FORMCHECKBOX None FORMCHECKBOX Adaptive cutlery FORMCHECKBOX Adaptive dinnerware FORMCHECKBOX Adaptive cups/mugs FORMCHECKBOX Adaptive kitchen aids FORMCHECKBOX Other (Specify): FORMTEXT ?????Equipment Recommended (based on the work-related injury) FORMCHECKBOX None FORMCHECKBOX Adaptive cutlery FORMCHECKBOX Adaptive dinnerware FORMCHECKBOX Adaptive cups/mugs FORMCHECKBOX Adaptive kitchen aids FORMCHECKBOX Other (Specify): FORMTEXT ?????Describe what assistance and/or assistive devices are required: FORMTEXT ?????Describe what the worker has eaten in the last 24 hours: FORMTEXT ?????HOMEMAKING SERVICESIndependentRequires AssistanceDependentWashing clothes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ironing clothes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Changing or making beds FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Light household cleaning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Heavier household cleaning FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Home maintenance tasks FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cleaning wheelchair or other devices FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shopping FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Grocery shopping FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Putting groceries away FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Assistance required (Specify frequency and time required): FORMTEXT ?????Are there any assistive devices that can be used to enhance independence? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe: FORMTEXT ?????MEDICAL OR PARA-MEDICAL REQUIREMENTSIndependentRequires AssistanceDependentDressing changes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medication regime FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Exercises FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Orthotics FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ordering supplies/equipment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Maintain supplies/equipment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Assistance required (Specify frequency and time required): FORMTEXT ?????SUPERVISION FORMCHECKBOX No monitoring required FORMCHECKBOX Monitoring during the night FORMCHECKBOX Monitoring during waking hours FORMCHECKBOX 24 hour supervision is requiredIf the worker requires monitoring, describe why: FORMTEXT ?????MENTAL STATUS (Psychological/Cognitive)Behaviors Noted or Reported FORMCHECKBOX Normal behavior noted FORMCHECKBOX Verbally abusive FORMCHECKBOX Restless FORMCHECKBOX Physically abusive FORMCHECKBOX Withdrawn FORMCHECKBOX Substance abuse FORMCHECKBOX Wanders FORMCHECKBOX Self-destructive behaviors FORMCHECKBOX Sexually inappropriateSafety Concerns (Specify): FORMTEXT ?????CognitiveOrientationPerson: FORMCHECKBOX Yes FORMCHECKBOX NoPlace: FORMCHECKBOX Yes FORMCHECKBOX NoTime: FORMCHECKBOX Yes FORMCHECKBOX NoIndependentRequires AssistanceDependentPlanning and organizing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Comprehension FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ability to initiate FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Insight FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Problem solving FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Decision making FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Attention/Concentration FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Objective observations of cognitive abilities: FORMTEXT ?????CommunicationIndependentRequires AssistanceDependentSpeech FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Word finding FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Written FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other (Specify): FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Objective observations of communication abilities: FORMTEXT ?????TRANSPORTATIONForm of Transportation FORMCHECKBOX Private vehicle FORMCHECKBOX Taxi FORMCHECKBOX Public transportation or DATSIs the worker independent in taking public transportation? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, why not and is this related to their work-related injury? FORMTEXT ?????Transportation Needs FORMCHECKBOX Work FORMCHECKBOX Leisure FORMCHECKBOX Appointments FORMCHECKBOX ShoppingHas their transportation changed since their work-related injury? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe the changes: FORMTEXT ?????VEHICLEDoes the worker own a vehicle? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe the year, make and model: FORMTEXT ?????Are there modifications to the vehicle because of the work-related injury? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe the modifications: FORMTEXT ?????BANKING/LEGAL AFFAIRSIndependentRequires AssistanceDependentBanking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Using an ATM FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Money management FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Writing cheques and managing accounts FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Legal affairs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX If the worker is dependent in any of the above areas, is this due to their work-related injury? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe: FORMTEXT ?????SELF-MANAGED CAREIn your opinion, does the worker have the skills and abilities to participate in a self-managed care program? FORMCHECKBOX Yes FORMCHECKBOX NoDescribe any additional training or community support that would be required for the worker to participate in a self-managed care program? FORMTEXT ?????Do you believe the worker needs to be monitored while on a self-managed care program? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, specify reasons for your concerns and how often they should be monitored. FORMTEXT ?????VOCATIONALIs the worker employed? FORMCHECKBOX Yes FORMCHECKBOX NoIs the worker engaged in productive behavior (e.g. school volunteer, etc.)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe: FORMTEXT ?????Is the worker interested in expanding their vocational options? FORMCHECKBOX Yes FORMCHECKBOX NoIs the worker attending classes? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe the class/program: FORMTEXT ?????IndependentRequires AssistanceDependentLevel of dependency FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Does the worker own a computer? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the worker own a smartphone? FORMCHECKBOX Yes FORMCHECKBOX NoIndependentRequires AssistanceDependentComputer use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Smartphone use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX How many hours/day on average does the worker use the computer/smartphone? FORMTEXT ?????RECREATIONDescribe the worker’s leisure interests/pursuits: FORMTEXT ?????IndependentRequires AssistanceDependentLeisure activities FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX How does the worker occupy his/her day? FORMTEXT ?????AIDS AND EQUIPMENTWith regards to their work-related injury, does the worker currently use assistive devices that are not described in the above sections? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe the devices used by the worker.For larger items note the make, model and year provided and the condition of the equipment FORMTEXT ?????Would the worker’s functional abilities improve (independence) if equipment was supplied to compensate for the work-related injury and the subsequent functional impairment? FORMCHECKBOX Yes FORMCHECKBOX NoSpecify what is recommended and how it will impact their ability to function. FORMTEXT ?????Is a follow up assessment required for aids/equipment, etc.? FORMCHECKBOX Yes FORMCHECKBOX NoADDITIONAL INFORMATIONDoes the worker have a care-giver? FORMCHECKBOX Yes FORMCHECKBOX NoAre there any specific issues with regards to the care-giver? (physical/emotional health, availability etc.)? FORMTEXT ?????Is the worker’s level of functioning consistent with what could be expected from the injury or disability? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, explain: FORMTEXT ?????RECOMMENDATIONSAll recommendations must be related to the worker’s work related injury under this specific claim. Please discuss any recommendations with the claim owner. FORMTEXT ?????Case conference date: FORMTEXT ????? (yyyy/mm/dd)Re-assessment recommended? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, re-assessment date: FORMTEXT ????? (yyyy/mm/dd)Rationale for re-assessment: FORMTEXT ?????If you have any questions regarding the information or would like to discuss, please contact the undersigned. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Provider’s NameTelephone NumberDate (yyyy/mm/dd)MEDICATION/MEDICATION MANAGEMENT RECORDMedication (including O.T.C.)DosageFrequencyDoctor’s Name and Phone Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Comment on overall ability to management medication (include obtaining prescriptions, safety, compliance, abuse). FORMTEXT ?????DAILY REPORTPlease indicate general occurrences for each hour. Include meals and amounts, bowel movements, sleep, procedures, therapies, recreation activities, baths, bed changing, medical or behavioral events, and so forth. There is room at the end to add comments or elaborate on an event. 5:00 a.m.: FORMTEXT ????? 6:00 a.m.: FORMTEXT ????? 7:00 a.m.: FORMTEXT ????? 8:00 a.m.: FORMTEXT ????? 9:00 a.m.: FORMTEXT ?????10:00 a.m.: FORMTEXT ?????11:00 a.m.: FORMTEXT ?????12:00 a.m.: FORMTEXT ????? 1:00 p.m.: FORMTEXT ????? 2:00 p.m.: FORMTEXT ????? 3:00 p.m.: FORMTEXT ????? 4:00 p.m.: FORMTEXT ????? 5:00 p.m.: FORMTEXT ????? 6:00 p.m.: FORMTEXT ????? 7:00 p.m.: FORMTEXT ????? 8:00 p.m.: FORMTEXT ????? 9:00 p.m.: FORMTEXT ?????10:00 p.m.: FORMTEXT ?????11:00 p.m.: FORMTEXT ?????12:00 a.m.: FORMTEXT ????? 1:00 a.m.: FORMTEXT ????? 2:00 a.m.: FORMTEXT ????? 3:00 a.m.: FORMTEXT ????? 4:00 a.m.: FORMTEXT ?????Comments: FORMTEXT ?????PHOTOS (IF APPLICABLE) ................
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