Five Hills Health Region

Five Hills Health Region
Physical/Occupational Community
Therapy Assessment
Location of Ax: ______
Source of Referral ______
Family Dr.: ______
CC Coordinator: ______/ Name: ______
Address: ______
Phone: ______Postal Code: ______
DOB: ______
PHN#: ______
DVA#:______
Reason for Referral:
Medical Hx: __CA __DM __ HTN __ CVA __ Cardiac (MI, arrhythmia, CHF, IHD) __ Resp __ Smoker __ Pacemaker
___ Osteoporosis ___ Surgeries:
Continence: Hearing:
Falls Screening Questions:
□ yes □ no 1. Have you had a slip, trip or fall in the past 6 months?
□ yes □ no 2. Are you taking 3 or more medications?
□ yes □ no 2. Are you taking a vitamin D supplement?
□ yes □ no 3. Are you taking sleeping pills, sedatives, or anti-depressants?
□ yes □ no 4. Has it been more than 6 months since your doctor or pharmacist reviewed your medications?
□ yes □ no 5. Has it been more than 12 months since your eyes were tested or your glasses checked by the eye doctor?
How is your vision?
□ yes □ no 6. Are there times when you are dizzy, light headed, unsteady, and drowsy or have blurred or double vision?
Prior Level of Activity/ADLs:
Social Situation /Support__ Lives alone __ Lives with ______Other Family______
IADL / Finances:
Meal Prep: / Home/Yard Maintenance:
Grocery Shopping: / Transportation:
Housekeeping: / Medications:
Laundry: / Other:
HOME ENVIRONMENT: / EQUIPMENT:
Housing style: / Bathroom:
Stairs outside: Rail __yes __no / Bedroom:
Stairs inside: Rail __yes __no / Living Room:
Other / Mobility Aids:
Physical Status:
Respiratory ______Pain (0/10 NRS) ______
Skin/Soft Tissue ______Oedema______
Blood Pressure: Lying (5 minutes): _____/_____ Standing: _____/_____ Standing 2 minutes: _____/_____
Cognition/Perception: Communication:
Testing completed □ Yes □ No Name of test(s):______
ROM:
Strength:
Sensation: / Coordination:
Berg Balance Assessment Score: ___/56 (Guidelines: ≥ 41- Independent Balance HEP; ≤ 40 PTA program)
Areas of concern:

Therapist Signature: ______Date: ______Time: ______

Function: Code - I = Independent IA= Independent with Aides S = Supervision A = Assist (min, mod, max)

ADL / Code / Comments
Toilet Transfer
Tub Transfer/Bathing
Dressing/Washing
Feeding
Functional Mobility / Code / Comments
Bed Mobility
Lie ßà Sit
Sit ßà Stand
Transfers
Ambulation
Stairs
Sitting Balance

Environmental Falls Risk Assessment:

Areas Assessed / Recommendations
Exterior:
□ Ramp/stairs
□ Lighting
□ Railings / □ Other ______
□ Recommend anti-slip material on surface of ramp/stairs ______
□ Make sure proper lighting in place ______
□ Rail needs to be: □ secured better □ Installed ______
Interior:
□ Flooring
□ Manoeuvrability
□ Lighting
□ Railings
□ Bathroom Safety
□ Furniture height/safety / □ Other ______
□ Remove throw rugs ______
□ Other flooring issues ______
□ Remove Clutter ______
□ Re-arrange Furniture ______
□ Ensure proper ramps (and also bevelled doorway thresholds, if needed) are in place, particularly if a 4WW or wheelchair is used
□ Ensure proper lighting is in place ______
□ Rail needs to be: □ Secured better □ Installed ______
□ Recommend knurled wall grab bars in bathroom: □ In bathtub □ Beside toilet
□ Recommend toilet armrests/raised toilet seat
□ Recommend/requisition appropriate bath seat/equipment
□ Adjust bed / chair / sofa to ______(ht.) □ remove casters ______
Other:
□ Assess for mobility aide
□ Check current mobility aide
□ Assess footwear / □ Other ______
□ Recommend mobility aide: ______OR □ mobility aide not required
□ Adjust mobility aide to ______(ht.)
□ Recommend footwear: low heeled, supportive with non-slip sole

Intervention and Plan:

□ Discussed Tx plan with client/caregiver and informed consent obtained. □ Falls Prevention Recommendations form given □ Equipment recommendation form provided □ Home Exercise Program implemented : □ Balance; □ Strength ______□ Follow-up with Therapist in ______weeks □ PTA falls prevention exercise program implemented
□ Community Therapy Brochure given
Other Recommendations:

Therapist Signature: ______Date: ______Time:______

Discharge Summary:

Berg Balance Re-Assessment: ____/56
PT/OT Discharge Plan:

Therapist Signature: ______Date: ______Time: ______

F00021

G:\Physio\Forms\Home Care Forms\F00021 - Home Care Assessment.doc DRAFT