Occupational Therapy Comprehensive Functional Assessment Summary
Basic Information
Individual Name:
First Name
Last Name
Date of Birth:
Age:
Location:
A1
A2
A3
B1
B2
B3
C2
C3
JT
SCL
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of evaluation:
-
Month
-
Day
Year
Date
Date of IPP meeting:
-
Month
-
Day
Year
Date
Type of evaluation:
Initial evaluation
Update
Comprehensive (3 year)
Diagnosis:
Changes and Recommendations
Changes from previous year?
Yes
No
Explanation of Major changes :
Strengths and needs summary:
Images (if applicable):
Browse Files
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of
Recommendation #1:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #2:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #3:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #4:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #5:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #6:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Name of evaluator completing update:
First Name
Last Name
Is this update complete?
Yes
No
Evaluator is:
CCHS Therapy
Contract Therapy
Evaluator Title:
Evaluator License #:
Evaluator Signature:
Review completed by:
Reviewer Title
Reviewer License #:
Reviewer Signature:
Muscle Tone
Muscle tone:
Physical Status
Physical description:
Range of Motion
Range of motion:
Within functional limits
Diminished
Strength and Endurance
Strength/endurance:
Within functional limits
Diminished
GROSS MOTOR:
Mobility:
Transfers:
Durable Equipment Used (LIST):
Sensation:
Within functional limits
Diminished
Fine Motor
FINE MOTOR
YES
NO
Picks up small objects
Transfers objects hand to hand
Marks with pencil
Turns pages of book one at a time
Copies circle from example
Cuts with scissors along a straight line
Hand dominance:
Right
Left
Opposition/finger touching:
Grip/grasp strength:
Functional
Diminished
Bilateral hand use:
Comments regarding fine motor:
COGNITIVE/COMMUNICATION
Expressive/Receptive Communication:
SENSORY:
Tactile:
Auditory:
Visual (pursuits/tracking):
Crossing Midline:
ADLS/SELF-HELP SKILLS:
EATING:
EATING:
ADAPTIVE EQUIPMENT-MEALS:
ADAPTIVE EQUIPMENT-MEALS:
Changes in eating over past year:
Needs/recommendations-meals/feeding:
ADL:
INDEP
SUPERVISION
ASSISTANCE
TOTAL SUPPORT
Bowels
Bladder
Oral Hygiene
Bathing/Showering
Brushing/combing hair
Selecting weather appropriate clothing
Dressing
Undressing
Bowel:
Continent
Incontinent
Bladder:
Continent
Incontinent
Durable Medical Equipment/Toileting used:
Comments regarding toileting procedures:
Comments regarding oral hygiene procedures:
Comments regarding Bathing/Showering procedures:
Comments regarding dressing procedures:
WHEELCHAIR STATUS:
Wheelchair currently used and or needed/in process:
YES
NO
Current wheelchair:
Serial #:
Date chair purchased:
Owner:
Current status:
Repairs over last year:
Needs/recommendations wheelchair:
BED RAIL ASSESSMENT:
Bedrail currently used and or needed/in process:
YES
NO
Alternatives attempted:
Wedges/bolsters to decrease rolling
Lower bed
Alert system
Grab bars
Trapeze
None
Risks associated with Bed Rail Use:
Requires head of bed to be elevated
Becomes combative with bed rails raised
Attempts to climb over rails
Lays with head against rails
Limps trapped between mattress and bed rail
Comments regarding bed rails:
Strengths & Needs Summary
Please write your narrative below:
Recommendations
Recommendation #1:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #2:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #3:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #4:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #5:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #6:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #7:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #8:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #9:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Recommendation #10:
What type of support:
Informal Support
POC
Menu
Other
Priority Program
Specific Support
Signature
Is this evaluation complete?
Yes
No
Evaluation completed by:
Evaluator is:
CCHS Therapy
Contract Therapy
Evaluator Title
Evaluator License #:
Evaluator Signature:
Review completed by:
Reviewer Title
Reviewer License #:
Reviewer Signature:
SUBMIT/COPY:
Email to receive copy of document:
example@example.com
Submit
Should be Empty: