Assessment Form Page 2
ADVERTISEMENT
1
2
3
4
5PATIENT NAME___________________________
PATIENT ID # ____________________________
FUNCTIONAL STATUS (continued)
Eating/Meal Preparation:
Communication: (writing/telephone/computer)
Dressing/Grooming:
Bed Mobility:
Bed hgt:
Toiletting:
Bladder:
Continent
Odd accident
Incontinent
Catheterised
Intermittent catheter
Bowel:
Continent
Odd accident
Incontinent
Equipment:
Transfers:
Seat hgt:
Comments:
Other Daily Activities, eg sport:
PHYSICAL EVALUATION
Visual Hx/Aids :
:
Intact
Impaired
Comments:
Visual Scanning/Acuity/Fields
Hearing :
Normal
Impaired
Deaf
Communication :
Verbal
Non-verbal
Method:
:
Cognition & Perception
Respiration :
Normal
Vent. dependent
02 dependent
Hx of chronic congestions
Equipment: (eg ventilator, battery, O2 cylinder, suction machine)
Dimensions:
Weight:
Sensation : (note areas that are abnormal or insensate)
Skin Integrity :
Intact
Hx of Sores
Red Area
Open Area
Scar Tissue
at risk from:
Orthotics
Prolonged Sitting
Poor Skin Condition
Moisture
Other
Comments:
Skin Inspection:
Independent
Assisted
Dependent
Method:
Independent
Assisted
Dependent
Pressure Relief:
Method:
Upper Limb Function:
(note coordination & strength )
R handed
L handed
Lower Limb Function:
(note amputation etc. )
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical