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BLUE BADGE ASSESSMENT FORM

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|Surname |      |Mr/Mrs/Miss/Ms/Other |      |

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|Forename |      |Date of Birth |      |

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|Postcode |      |Address the same |ID Type & Number |      |

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|Does the assessed client bear a true likeness to the photograph supplied? Yes No |

|Other Person(s) Present: | Yes No |Assisting with Interpreting Yes No |

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|Name |      |Relationship to Client |      |

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|Start Time |      |Finishing Time |      |

|Blue Badge User? | Yes No |Car Driver? | Yes No |

|DLA Applied | Yes No |DLA Approved (Higher Rate)? | Yes No |

|Why are you applying for a Blue Badge? |

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|Health / Disability / Impairment (Documented Evidence) |

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|Cardiac |

|Pulmonary |

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|Angina |

|Chronic Obstructive Pulmonary Disease |

|(COPD) |

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|Ischemic Heart Disease |

|Asthma |

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|Myocardial Infarction (heart attack) |

|Emphysema |

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|Other cardiac disease |

|Other lung disease |

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|Musculo-skeletal |

|Other |

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|Osteoarthritis |

|Cancer |

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|Rheumatoid arthritis |

|Hypertension |

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|Osteoporosis |

|Diabetes |

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|Osteopaenia |

|Glaucoma/Cataract/Macular Degeneration |

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|Chronic back pain |

|Frailty associated with age |

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|Joint replacement |

|Deafness or hearing loss |

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|Fracture or dislocation |

|Incontinence |

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|Neurological |

|Mental Health |

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|Parkinson’s Disease |

|Depression |

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|Cerebral Vascular Accident (stroke) |

|Anxiety / Panic Disorder |

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|Multiple Sclerosis |

|Bi-polar Disorder |

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|Dementia |

|Reduced Cognitive Ability |

|(memory/confusion/orientation) |

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|Alzheimer’s Disease |

|Other (please state below) |

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|Paediatric |

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|Autistism / Asperger’s Syndrome |

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|Learning Disability |

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|Developmental Delay |

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|Juvenile idiopathic arthritis |

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|Down’s syndrome |

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|Congenital diseases/conditions |

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|Additional information: |

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|Medications |

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|Anti-hypertensives / Cardiac: |

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|Amlodipine |

|Atenolol |

|Bendroflumethiazide |

|Bisoprolol |

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|Clopidogrel |

|Digoxin |

|Enalapril |

|Irbesartan |

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|Losartan |

|Perindopril |

|Propanolol |

|Ramipril |

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|Warfarin |

|Doxyzosin |

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|Propanolol |

|Ramipril |

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|Analgesics: |

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|Co-codamol |

|Co-dydramol |

|Diclofenac |

|Gabapentin |

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|Naproxen |

|Morphine |

|Lidocaine injection |

|Codeine |

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|Ibuprofen |

|Paracetamol |

|Tramadol |

|Aspirin |

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|Breathing: |

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|Steroid Inhaler |

|Oxygen |

|Salbutamol |

|Tiotropium |

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|Diabetes: |

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|Gliclazide |

|Insulin |

|Metformin |

|Pioglitazone |

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|Sitagliptin |

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|High cholesterol: |

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|Atorvastatin |

|Simvastatin |

|Pravastatin |

|Ezetimibe |

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|Other statin |

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|Anti-depressants |

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|Amitriptyline |

|Citalopram |

|Fluoxetine |

|Mirtazapine |

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|Sertraline |

|Venlafaxine |

|Nortriptyline |

|Paroxetine |

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|Other anti-depressant (state below) |

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|Diuretics |

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|Forusemide |

|Indapamide |

|Isosorbide |

|Spironolactone |

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|Other Medicines |

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|Lanzoprazole / Omeprazole (peptic conditions) |

|Lactulose (constipation) |

|Calcichew |

|(osteoporosis) |

|Ferrous sulphate (anaemia) |

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|Levodopa |

|(Parkinson’s Disease) |

|Levothyroxine |

|(thyroid problems) |

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|Anti-histamines |

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|Anti-biotics / anti-fungals |

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|Topical Creams |

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|Vitamins and minerals (must be prescribed) |

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|Evidence Shown (dated      ) : |

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|Verbal |

|Prescription |

|Medicine Boxes |

|Medical report / letter |

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|Additional information about medication: |

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|History and dates of medical investigations and interventions: |

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|Visit to see specialist (please state):       |

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|Surgery (please state):       |

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|Scan (type and reason):       |

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|Physiotherapy Hydrotherapy (reason):       |

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|Gastroscopy Colonoscopy Arthroscopy Biopsy of:       |

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|Blood tests (please state if known):       |

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|Other therapeutic intervention (please state):       |

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|Forthcoming medical investigations including dates: |

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|Visit to see specialist (please state):       |

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|Surgery (please state):       |

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|Scan (type and reason):       |

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|Physiotherapy Hydrotherapy (reason):       |

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|Gastroscopy Colonoscopy Arthroscopy Biopsy of:       |

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|Blood tests (please state if known):       |

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|Other therapeutic intervention (please state):       |

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|Assessment suggests that the disability/prognosis is: |

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|Permanent |

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|Deteriorating |

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|Temporary |

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|Intermittent |

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|Other information relevant to medical details: |

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| |5 / AUTOMATIC |4 |3 |2 |1 |0 |SCORE |

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|On average, how long does it take you to walk to the station/bus stop? How do you manage? |

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|Time taken: |

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|Stops en route: |

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|Terrain: |

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|Boarding and alighting transport |

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|Support needed |

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|Additional information: |

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|Transport Mode |

|Usage & Frequency |

|Difficulties Experienced |

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|BUS |

|Uses Does not use |

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|Frequency: per |

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|TRAIN |

|Uses Does not use |

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|Frequency: per |

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|TAXI |

|Uses Does not use |

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|Frequency: per |

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|PRIVATE |

|Uses Does not use |

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|Frequency: per |

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|How did you travel to the mobility clinic today? (transport, parking, support required, difficulties) |

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|Type of Transport: |

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|Support Needed: |

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|Additional information: |

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|Self Care Tasks |

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|Ability: |

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|Use of Bath/Shower: |

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|Other information: |

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|Domestic Tasks: |

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|Shopping: |

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|Cooking: |

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|Cleaning: |

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|Other information |

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|What are your daily routines? (leisure activities, work, family commitments) |

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|Work or school |

|Look after |

|children |

|I take children to |

|school |

|Social activities |

|and visits |

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|Religious |

|attendance |

|I am a carer |

|Voluntary activity |

|Medical/ other |

|appointments |

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|I stay at home |

|I watch TV |

|Reading |

|Shopping |

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|Dog walking |

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|Other Information       |

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|What aids do you use at home? |

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|Bathing aids |

|Bed aids |

|Grab rails |

|Toilet aids |

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|Seating aids |

|Special chair |

|Kitchen aids |

|Dressing aids |

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|Other information |

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|What adaptations do you have at home? |

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|Stair rail(s) |

|Shower |

|Ramp |

|Stairlift |

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|Other information |

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|Do you receive or pay for any other support services? (eg: HomeCare, District Nurse, Support Worker) |

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|Psychological / Emotional / Behavioural Factors (observed and/or reported) |

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|5 |

| |WNL |Min |Mod |High |Comments including any discrepancies |

|Head and Neck | | | | | |

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|Trunk | | | | | |

|(R) Upper Limb | | | | | |

|(L) Upper Limb | | | | | |

|(R) Lower Limb | | | | | |

|(L) Lower Limb | | | | | |

|Overall effect on walking | | | | | |

|Joint/Limb Swelling | | | | | |

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|INDOOR ASSESSMENT |

|Where did the client walk to during the mobility assessment, noting any obstacles? |

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|Distance:       metres Time taken:       minutes       seconds |

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|Where walked?       |

|AREA OF ASSESSMENT |OT OBSERVED |

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|OUTDOOR ASSESSMENT |Distance:       metres Time taken:       minutes       seconds |

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|Observe entering and exiting the assessment room, |Where walked?       |

|plus walking assessment up to 101 metres total. | |

| |Kerb: |

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| |Uneven Surfaces: |

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| |Slope: |

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|5 |4 |

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|5 |

|AREA OF ASSESSMENT |CLIENT REPORTED / OT OBSERVED |

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|LENGTH OF TIME / TOLERANCE | |

| |CLIENT REPORTED |

|Pain reported or external indicators |OT OBSERVED |

|Fatigue observed (exerted) | |

|Breathing SOB, SOBOE, Quality |Pain: |

|Standing Tolerance minutes | |

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| |Fatigue: |

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| |Breathlessness |

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| |Standing Tolerance: |

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| |Exertion: |

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| |Stress: |

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|5 |4 |3 |2 |1 |0 |SCORE |

|AREA OF ASSESSMENT |OT OBSERVED |

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|MANNER OF WALKING | |

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|Static / dynamic balance |Static Balance: |

|Transfer in/out of chair independently or with | |

|assistance | |

|Gait Rhythm |Dynamic Balance: |

|Co-ordination | |

|Falls Risk – within past year | |

|Falls indoor/outdoor |Gait: |

|Support required at any point during the walk | |

|Ability to use steps with/without rail | |

| |Co-ordination: |

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| |Falls in last year: |

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| |Support Required: |

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| |Ability to use steps: |

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| |Sit to stand transfer: |

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|5 |4 |3 |2 |1 |0 |SCORE |

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|MOBILITY MATRIX SCORE |

|ASSESSMENT AREA |

|SCORE |

|POSSIBLE MAXIMUM |

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|Health |

|(p2/3) |

|5(automatic) |

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|Transport |

|(p4) |

|5 |

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|ADL |

|(p5) |

|5 |

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|Mobility Aids |

|(p6) |

|5 |

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|Mobility |

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|Distance |

|(p7) |

|5(automatic) |

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|Speed |

|(p8) |

|5 |

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|Length Of Time / Tolerance |

|(p8) |

|5(automatic) |

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|Manner Of Walking |

|(p9) |

|5 |

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|Total |

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|40 |

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|Suggested Eligibility Cut-offs: |

|BB: 24 < (must have 13 or greater in Mobility component). |

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|THE APPLICANT MEETS THE CRITERIA FOR: |

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|Blue Badge |

|Yes No |

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|Review Prior To Renewal |

|Yes No |

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|Reason(s): |

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|ADDITIONAL JUSTIFICATION |

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|SUMMARY OF ASSESSMENT (FOR LETTER) |

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|SIGNED: | |DATE: |      |

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|NAME: | |PROFESSION: |OCCUPATIONAL THERAPIST |

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CLIENT DETAILS

1. Health

2. Current Transport Used

3. ACTIVITIES OF DAILY LIVING

4. MOBILITY AIDS

5. MOBILITY

ADDITIONAL COMMENTS

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