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Functional Assessment Patient's Name:_____________________________________ Date: _________________ Date of Birth:_________________ Current Living Arrangements:____________________ ______________________________________________________________________________ Relationship to Applicant/Person completing This Form:_________________________ Patient _______________ Patient 's Medical Diagnoses:________________________________________________ ______________________________________________________________________________ For each area of functioning listed below, please describe to the best of your ability the amount and type of assistance the applicant requires. BATHING Does patient take a shower, tub bath or sponge bath?_______________________ How often does he/she bathe?________________________________________________ How much assistance is needed?______________________________________________ DRESSING How much assistance does patient receive in dressing (including selecting and getting clothes from closet, putting on undergarments and using fasteners)? ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Additional Comments_________________________________________________________ ___________________________________________________________________ ____________ ______________________________________________________________________________________ TOILETING Does patient require assistance with toileting (including getting to and from bathroom, cleaning self after elimination and arranging clothes)?_______________ If yes, how much assistance is needed?________________________________________ ______________________________________________________________________________ Does patient have a catheter? What type?_________________________________ Does he/she have a colostomy?_______________________________________________ Is patient able to control urination?____________ Bowel movements?__________ If no, how often do "accidents" occur?_________________________________________ MOBILITY Does patient walk (list assistive devices used, i.e., walker, cane) or does he/she use a wheelchair?________________________________________ Does he/she need assistance getting out of bed or a chair?____________________ If yes, how much assistance is needed?________________________________________ ______________________________________________________________________________ EATING Does patient feed self or require assistance eating?__________________________ ______________________________________________________________________________ Does he/she use adaptive equipment while eating (i.e., plate guard, special spoon, etc.)?_________________________________________________________________ Is he/she on a special diet?____________________________________________________ How would you describe patient's appetite?_________________________________ Height_______________________________ Weight_______________________________ MEDICATION List patient's current medications:____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Any known drug allergies?_____________________________________________________ ______________________________________________________________________________ Is patient using oxygen (if yes, how much and how often)?___________________ ______________________________________________________________________________ PROSTHESES Does patient have an arm or leg prosthesis?_________________________________ Does he/she wear dentures (upper and lower)?________________________________ Does he/she use a hearing aide?______________________________________________ SKIN Does patient presently have bed sores (if yes, where and for how long)?______ ______________________________________________________________________________ Does he/she have skin rashes?_________________________________________________ Does he/she experience swelling of the legs or feet?____________________________ ______________________________________________________________________________ ORIENTATION Is patient alert and oriented or does he/she exhibit confusion? (If confused, is it ongoing, often, or occasional?)______________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ For individuals who are confused and disoriented: Does the patient attempt to wander?_______________________________________ If yes, how often?_____________________________________________________________ Is he or she willing to return if given direction?__________________________________ OTHER HEALTH CONSIDERATIONS Does patient currently use physical or chemical restraints? If yes, describe type and frequency:__________________________________________________________ ______________________________________________________________________________ Has he/she ever been hospitalized for any other health problems? If yes, state when, where, and why:_______________________________________________________ ______________________________________________________________________________ Does patient maintain active and satisfying relationships with family and friends?_______________________________________________________________________ ______________________________________________________________________________ Does he/she have a history of drug or alcohol abuse? If yes, please describe:___ ______________________________________________________________________________ ______________________________________________________________________________ Is patient currently receiving physical, occupational, speech, or respiratory therapy? If yes, list type of therapy, reason for, and frequency received:________ ______________________________________________________________________________ ______________________________________________________________________________ Additional Comments:________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What are your recommendations? |
| Nutritional assessment |
| Counseling/Functional Behavioral Assessment |
| Physical Activity Guidelines |
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Revision of diagnosis And/or |
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Crutches & Accessories Electric & Power Wheelchairs Manual Wheelchairs
Bariatric Wheel Chairs Extra Wide Wheelchairs - 22in Seats Lightweight Wheelchairs - 16in Seats Pediatric Wheelchairs Recliner Wheelchairs Travel & Transport Wheelchairs Wheelchair Accessories Wheelchairs - 18in Seats Wheelchairs - 20in Seats
Dual Release Walkers Hemi Walkers Lightweight Walkers Pediatric & Junior Walkers PVC Walkers Single Release Walkers Walker Accessories Rollators & Wheeled Walkers Walking Canes Wheelchair Accessories Wheelchair Cushions
Bariatric Wheelchair Cushions Gel Cushions Pressure Reducing Cushions Wheelchair Pads Mobility
Bariatric Scooters Bariatric Walkers Bariatric Wheelchairs Bariatric Wheelchairs Canes, Crutches & Walkers Electric Wheelchairs Lift Chairs & Information Lightweight Wheelchairs Manual Wheelchairs Medical Mobility Ramps Medical Walkers Mobility Scooters Motorized Wheelchairs Pediatric Wheelchairs Portable Wheelchair Ramps Portable Wheelchairs Power Wheelchairs Rollators Wheelchair Accessories Ab Exercise Equipment Dumbbells and Accessories Electrotherapy & Accessories
Electrotherapy Accessories Peripheral Nerve Stimulators Tens Units Foot Baths Hot & Cold Therapy
Cold & Ice Packs Fire Cupping Heating Pads & Packs Hot & Cold Therapy Equipment Hot and Cold Packs Nylatex Wrap
Full Body Hydrotherapy Immersion Tanks Whirlpool Tubs Hydrolift Hydrotherapy Whirlpools Hydrotherapy Whirlpool Bath Tubs Podiatry Hydrotherapy Whirlpool Bathtubs Slant Back Whirlpool Bath Tubs Sports Whirlpool Bath Tubs Whirlpool Accessories Traction Magnet Therapy Traction Massagers & Accessories
Massage Accessories Traction Massage Oils, Lotions & Gels Traction Massagers
Taping Tables & Stations Traction Tables Parallel Bars Pedometers Professional Massage
Massage Chairs Massage Table Accessories Portable Massage Tables Stationary Massage Tables (10) Rehabilitation & Exercise Equipment
Cardio Equipment Dumbells Exercise Pulley & Stretching Equipment Fingers & Hand Exercisers Fitness & Exercise Balls Floor Mats & Platforms Foam Rollers General Exercise Products Intracells Resistance Bands Resistance Tubing Resistance Weight Lifting Equipment Resistant Cords Shape Belts Wrist & Ankle Weights Standing Frames & Tables Traction Therapy
Pneumatic Compression Device Posture Pump Spine Trainer Treadmills Weight Racks etc. Do you have any recommendations? Would you like to add anything? Would you like to Teach Dr. Qureshi's Physical Medicine & Rehabilitation? |