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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 |
-----------------------
CLIENT DETAILS
1. Health
2. Current Transport Used
3. ACTIVITIES OF DAILY LIVING
4. MOBILITY AIDS
5. MOBILITY
ADDITIONAL COMMENTS
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