Equipment Prescription Form LSA .au
Complete eligibility screen before proceeding with this prescription
|Client name: | |Sex: M F | Other | |DOB: | |
|Address: | |Phone No: | |
|Clinician: | |Division: | |Date: | |
|People consulted: | |
Medical History
|Diagnosis/Prognosis: | |
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|Pain: | |
|Height: | |Weight: | | |
|Sensation: (note areas that are abnormal or insensate) | |
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|Skin history/integrity: | |
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|Pressure relief: Independent Assisted |
|Methods used: | |
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|Cushions: | |
|Bladder: Continent Incontinent |Management: | |
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|Bowel: Continent Incontinent |Management: | |
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Social History
Environment (note space for chair, other furniture, access to power point, floor surface etc.)
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|Activity configuration (note time spent in chair, activities to be done in chair etc) |
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|Current chair(s) used: | |
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|Other options available at home: | |
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Transfers/ Mobility
Ambulation status:
Transfer onto chair:
Transfer off chair:
Weight shifting in chair:
Carer needs in assisting Client:
Basic dimensions:
Height: _____ Weight: _____ A: Seat-elbow ____ B: Back of knee-heel _____
C: Posterior of buttocks-back of knee _____ D: Widest point at hips or thighs _____
Options for Chair
Control: Left Right
Customisation needed Yes No Details:
Fabric preference: (vinyl, dartex, synergy, cloth, colour etc.)
Incontinence covers required Yes No
Armrest covers: Yes No
Wall-saver function required Yes No Justification:
Dual motor required: Yes No Justification:
Client Goals And Concerns
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Additional Notes/Summary
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|Short Term Plan(s): |Trial equipment : | |
| |Date/Place: | |
| |Obtain further info | |
| |Other | |
|Info given to client: | Terms and Conditions |
| |‘Preventing Pressure Sores’ pamphlet as indicated |
| |Other: |
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|Clinician Name: | |
|Clinician Signature: | |Date | |
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