Title:
Surname:
First Name:
Date of Birth: (dd/mm/yyyy)
Address:
Tel No: / GP:
Address:
If you receive help from any of the services listed below, please tick the relevant box:
Home Care
Meals on Wheels
Social Worker
District Nurse
Physiotherapist
Day Centre
Other
Do you live alone? Please SelectYesNo
If No, who with?
Next of Kin – Or Emergency Contact Information:
Do you have a disability or long-term medical condition? Please SelectYesNo
If Yes, please give details
Does someone help you? Please SelectNoYes
If Yes, who?
Are you a permanent wheelchair user? Please SelectNoYes
Height: / Weight:
PROPERTY DETAILS
Please provide information or select the correct answer: -
1. Type of accommodation, e.g. bungalow, terrace house, flat etc.
2. Who owns the property?
Yourself or your family
Private Rent
Housing Association
If Housing Association, Please state which one:
Sheltered Accommodation
TMO/Council Housing
Partly Yourself/Part Rent
Please list your main difficulties in order of priority e.g. getting in or out of the bath:Ø
Ø
Ø
Ø
Have you ever bought or been prescribed equipment? Please SelectNoYes
If Yes, please list the equipment?
DAILY ACTIVITES
Please only fill in the sections that are relevant to the problems you are having
SECTION A – MOBILITY
Do you have any difficulty walking?
Is this an area you would like help with? / Please SelectNoYes
Please SelectNoYes
Do you have any equipment that you use when you walk?
(e.g. walking stick, walking frame)
How long can you comfortably stand for?
Have you fallen recently? / Please SelectYesNo
If so what happened?
Do you fall frequently? / Please SelectYesNo
If yes, how often?
Do you have any problems with your balance? / Please SelectYesNo
If yes, please describe them
Have you recently seen a physiotherapist?
SECTION B – EXTERNAL & INTERNAL ACCESS TO YOUR PROPERTY
Do you have any difficulties accessing your property either externally or internally
Is this an area you would like help with? / Please SelectNoYes
Please SelectNoYes
If your answer to either of the above is No – please move to the next section
Are there any steps at the front of your property? / Please SelectYesNo
If yes, how many steps?
Are the steps communal? (do other people use them to get to their own property)
Are you able to manage these steps? / Please SelectYesNoWith difficulty
Is there a rail at these steps? / Yes, one rail
Yes, two rails
No
N/A
Is there a lift in the property / Please SelectYesNo
If yes, do you still need to manage some steps to get out of the property
How many levels are inside your property?
If you have more than one level are you managing the stairs between the floors? / Please SelectYesNoN/A
If you have more than one level is there a rail on your main staircase? / Yes, one rail
Yes, two rails
No
N/A
Are there any other steps in your property? / Please SelectYesNo
If yes, how many?
Are you able to manage these steps? / Please SelectYesNoWith difficulty
Is there a rail at these steps? / Yes, one rail
Yes, two rails
No
N/A
Are any of your stairs curved? / Please SelectYesNo
If so, which set of stairs?
SECTION C – USING THE TOILET
Do you have difficulties getting on and off your toilet?
Is this an area you would like help with? / Please SelectNoYes
Please SelectNoYes
If your answer to either of the above is No – please move to the next section
What is the difficulty?
What support do you feel that you need to help you? / I would like:
my toilet seat to be higher
my toilet seat to be lower
rails by my toilet
Other
Where is your toilet? / Same floor as your lounge
Same floor as your bedroom
Both of the above
Neither
Can you get to your toilet on time? / Please SelectYesNo
Height of toilet?
Is the large outflow pipe at the back or side of the toilet? / Yes, back of the toilet
Yes, side of the toilet
No
SECTION D – USING THE BED
Do you have any difficulties getting on and off your bed?
Is this an area you would like help with? / Please SelectNoYes
Please SelectNoYes
If your answer to either of the above is No – please move to the next section
Can you lift your legs in and out of your bed? / Please SelectYesNoWith difficulty
Can you sit up from lying down? / Please SelectYesNoWith difficulty
What type of bed do you have?
(e.g. single, double, divan, electric, hospital)
Please select the picture that looks most like the legs on your be:
Do you need the support of holding onto something when getting on and off your bed?
If so, what do you hold on to? / Please SelectYesNo
Is there enough space to easily walk around your bed?
SECTION E – USING THE CHAIR
Do you have difficulties getting on and off your chair?
Is this an area you would like help with? / Please SelectNoYes
Please SelectNoYes
If your answer to either of the above is No – please move to the next section
Do you need the support of holding on to something when getting on and off your chair?
If so, what do you hold on to? / Please selectNoYes
What type of chair is it?
(e.g. armchair, recliner chair, sofa, sofa bed)
Please select the picture that looks most like the legs on your chair
SECTION F – BATHING
What bathing facilities do you have? / Bath
Shower cubicle
Bath with over-bath shower
Bath & Shower cubicle
Are you able to get in and out of this?
Is this an area you would like help with? / Please SelectYesNoWith difficulty
Please SelectYesNo
If your answer to either of the above is No – please move to the next section
What difficulties do you have? / I am not able to step in and out of the bath
I am not able to get up from the bottom of the bath
Other
Do you need the support of holding onto something?
What do you need to hold onto? / Please SelectYesNo
Have you ever fallen when bathing? / Please SelectYesNo
Have you ever got stuck in the bath? / Please SelectYesNo
Can you turn your taps on and off? / Please SelectYesNo
What help do you feel that you need?
Please give measurements of the width of your bath?
What type of bath do you have?
(e.g. plastic, enamel)
SECTION G – WASHING
Do you have difficulties washing yourself?
Is this an area you would like help with? / Please SelectNoYes
Please SelectNoYes
If your answer to either of the above is No – please move to the next section
What difficulties do you have?
Can you wash your back? / Please SelectYesNoWith difficulty
Can you wash your feet? / Please SelectYesNoWith difficulty
Can you dry yourself? / Please SelectYesNoWith difficulty
SECTION H – DRESSING
Do you have difficulties dressing yourself?
Is this an area you would like help with? / Please SelectNoYes
Please SelectNoYes
If your answer to either of the above is No – please move to the next section
What difficulties do you have?
Can you fasten buttons? / Please SelectYesNo
Can you do up zips? / Please SelectYesNoWith difficulty
Can you put your shoes on? / Please SelectYesNo
Can you put on your socks/stockings / Please SelectYesNo
SECTION I – MAKING A SNACK/MEAL
If you have no difficulty with making a snack/meal please go straight to the next section.
Do you have difficulties making a hot drink?
Is this an area you would like help with? / Please SelectYesNoWith difficulty
Please SelectYesNo
If yes, What are the difficulties?
(e.g. pouring the kettle, turning taps, opening bottles)
Do you have difficulties making a snack/main meal?
Is this an area you would like help with? / Please SelectYesNoWith difficulty
Please SelectYesNo
If yes, What are the difficulties?
(e.g. opening bottle/tins, the cooking controls, standing for long periods of time)
Where do you sit to eat your food?
Can you carry your food/drink to where you eat? / Please SelectYesNoWith difficulty
SECTION J – HEARING & SIGHT
If you have no difficulty with hearing or seeing please go straight to the next section.
Do you have any difficulty hearing?
Is this an area you would like help with? / Please SelectNoYes
Please SelectNoYes
If yes, what do you have difficulty hearing?
(e.g. telephone, television, door bell)
Do you wear glasses? / Please SelectYesNo
Is there anything in your property that you have difficulty seeing?
Is this an area you would like help with? / Please SelectYesNo
Please SelectYesNo
If yes, what do you have difficulty seeing?
(e.g. television, controls)
SECTION K – MANAGING YOUR HOUSEWORK, SHOPPING AND FINANCES
If you have no difficulty with managing your housework, shopping and finances please go straight to the next section.
Do you have any difficulty managing your housework?
Is this an area you would like help with? / Please SelectNoYes
Please SelectNoYes
If yes, what are the difficulties?
Do you have any difficulty managing your shopping?
Is this an area you would like help with? / Please SelectYesNo
Please SelectYesNo
If yes, what are the difficulties?
Do you have any difficulty managing your finances?
Is this an area you would like help with? / Please SelectYesNo
Please SelectYesNo
If yes, what are the difficulties?
Is there anything else you feel we should know?
If you have someone who helps to care for you, please also complete the Carers Assessment form. This form can be found on the Occupational Therapy front page.
If you would prefer to post your form please send it to your local Occupational Therapy team:
Occupational Therapy North
Westway Information and Advice Centre
140 Ladbroke Grove
W10 5ND
Tel: 020 7598 4430
Occupational Therapy South & Central
282 Earls Court Road
SW5 9AS
Tel: 020 7598 4945
1