OCCUPATIONAL THERAPY ASSESSMENT FORM



SOCIAL CARE OCCUPATIONAL THERAPY ASSESSMENT FORM FOR CHILDRENNAMEADDRESS Post Code: Telephone Number: Email address: Date of BirthAge: Emergency contactName: Relationship: Telephone no: Family DoctorTel: 020 Fax: 020 Email: SchoolTel:Ethnic backgroundReason for visitReferred by: Date of referral: Physical condition & medical historyAs described by the child / parent / carerMedication:HOME SET UPHome & Family situationList all people living in the propertyNameRelationshipDoBSupport networks & Agencies?OT?PT?SALT?School ?Consultant?CAMS?Other Owner of the propertyAny tenantOn a housing transfer list? ? yes ?no?LBS propertyAHO :On the right to buy scheme? ? yes ?no?Private landlord *?Housing Association **contact details?Owner Occupier ?Other tenure Layout of Property? House ? Flat ? Maisonnette ? BungalowIs there a smoke alarm in the property? ?Yes ?No Would you like home fire safety visit check? ?Yes ?No Access(Inside and outside)INFORMATION ABOUT MACROBUTTON NoMacro [Click here and type child's name]Communication Skills & methods ? Can the child make eye contact??Does the child recognise parent / familiar person??Does the child make age appropriate sounds? If not, does the child ?picture ?symbols communicate using: ?switches ?Other ? Other comments on eyesight / hearing / speech: Is a more specialist assessment required? ? Yes ? NoGeneral BehaviourSafety awareness: Sleep patterns: Other comments: GETTING AROUNDIndoorsEquipment used: Outdoors(level ground, uneven ground, steps/ kerbs)Equipment used: ?Blue Badge ? Taxi card ? Motability On the stairsIndoors & outdoorsAny history of fallsFalls indoors ? outdoors ? give details:Physical Assessment PoorFairGoodAACommentsMotor control Upper body ????(reach, grasp, bilateral hand use, hand preference, co-ordination, active or passive movement possible, contractors)Lower body????Tone ????Sitting balance / posture ????Head stability????(Head / neck function: level of support needed)Standing balance????Pivot Transfers ????Walking ability????(level of support needed: static: dynamic)Supine / prone mobilityBridging????Rolling ????Motivation????Cognitive abilities????YesNoCommentsPain??History of seizures??Fluctuating function??Behavioural issues??PEG, trachea, other??Body measurement Height : Weight:Hip width: Arm span:Upper leg length: Lower leg length:Back height:Moving and handling – carers and environmentHas a moving & handling need been identified? ?Yes ?No If yes completed the following section Parent ? Carer ? Formal carer ?Is the person happy for a joint approach to the M&H assessment and joint record keeping? ? Yes ? NoPoorFairGoodCommentsExperience???Confidence???Physical condition???Communication???Other???EnvironmentPoorFairGoodCommentsTurning circle???Circulation???Floor covering???Lighting???Other???EVERYDAY LIVING TASKS1 INDEPENDENT3 INDEPENDENT WITH EQUIPMENT2 INDEPENDENT WITH DIFFICULTY4 MANAGES WITH HELP OF SOMEONE ELSE5 UNABLE TO DOAssessment to manage tasks is linked to what you would normally expect a child of the same age to be able to do.O OBSERVEDR REPORTED12345CommentsTOILETHeight:Getting onGetting offManaging clothesWiping selfFlushing WCBEDHeight:Getting onGetting offRaising self from lyingRepositioning CHAIRHeight:Getting onHeel to popliteal fossa:Getting off1 INDEPENDENT3 INDEPENDENT WITH EQUIPMENT2 INDEPENDENT WITH DIFFICULTY4 MANAGES WITH HELP OF SOMEONE ELSE5 UNABLE TO DOBATH / SHOWERHeight / width / depth: Plastic / metalGetting inGetting outWashing (Including hair)DryingTurning tapsGROOMING & PERSONAL HYGIENEManaging hairCleaning teethMenstruationWashing handsDRESSING & UNDRESSINGUpper bodyLower bodyFastenings1 INDEPENDENT3 INDEPENDENT WITH EQUIPMENT2 INDEPENDENT WITH DIFFICULTY4 MANAGES WITH HELP OF SOMEONE ELSE5 UNABLE TO DOEATING & DRINKINGHolding cutleryHolding cupKitchen tasksDOMESTIC JOBSHelping with house hold jobsUsing appliances Equipment & adaptations already in placeOccupational TherapyMedical / Health equipmentWheelchair servicePrivately purchasedOtherPlay / LeisureFinancesFor under 16 year olds? DLA for children ?Care low / middle / high ?Mobility low / high Over 16 ? PIP ?Care low / middle / high ?Mobility low / high Other :Race & cultural issues Parents / Carers Views & issuesMain Carer: ? Informal ?FormalAware of carers support groups ?Yes ? No Informal carer only:Have carer needs been identified? ?Yes ?No Is a formal carer’s assessment required? ?Yes ?No ?Declined WHAT HAS BEEN AGREED FROM THE VISITIdentified issues Risk levelShort term actionLong term actionChild / parent / carer comments about the OT assessment and recommendationsInformation & advice provided and onward referrals DateInfo/advice providedAssessment conducted Does this assessment report include a Moving & Handling Assessment? ?Yes ?No If yes a Safer Handling Plan is required.Date assessmentAssessorPresent on visitBeginEndChild’s DetailsName: Address: Permission to obtain additional information and share information with others ? I give permission ? I do not give permissionfor the Occupational Therapy Service to contact our GP, Hospital Consultant or other relevant professional or person involved in my child’s care to obtain more informationabout my child’s medical condition and/ or functional level.Record of any limitations: ? I am willing ? I am not willing I am willing for information to be passed onto or discussed with other health, social care or education staff if this will help meet my child’s needs. Signed : ________________________________________________________Print Name: ______________________________________________________Relationship to Child: ______________________________________________Date: _____________________________________Append to assessment report dated ………………….. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download