Initial Assessment OT working

Date of Ax: [date]
Persons present: [text]
Settting : [checkbox name="Social" value="Residential aged care facility. |Private residence."]
Client name: [textarea name="ClientName"]
[checkbox name="Sex" value="Male|Female"]
DOB: [date]
Diagnosis: [checklist name="Diagnosis" value="Cerebral vascular disease |Congestive heart failure |COPD |Dementia|Degenerative disc disease|Falls |Diabetic neuropathy|Dialysis |Dizziness|Fixed hip angle |Hemiplegia|Muscle weakness |Obesity|Pressure ulcer|SCI|Osteoarthritis|Parkinson’s disease|Rheumatoid arthritis |Traumatic brain injury |Upper body instability |Wheelchair user |Age-related Decline"]
Social history: [checkbox name="Social" value="Living at home alone. |Living at home with support. |Living with family/husband/partner|"]
Supports/services: [checklist name="services" value="Domestic cleaning|Gardening|Personal carers|Shopping|Community Access|Meal preparation"]
Falls History: [checkbox value="None|Occasional|Frequent|Risk of falls"]
Skin Breakdown: [checkbox value="Present|None currently|History of"]
Ambulation:
Maximum distance ambulated independently: [checkbox value="<10m|>10m|>20m|>50m|>100m"]
Cane/SPS:[checkbox value="not using|unable to use d/t upper extremity weakness|unable to use d/t upper extremity pain|unable to use d/t lower extremity weakness|unable to use d/t dizziness"]
4WF/Walker:[checkbox value="not using|limited use d/t fatigue|limited use d/t dizziness|uses with assistance|unable to use independently d/t upper extremity weakness|unable to use independently d/t upper extremity limited range of motion|unable to use independently d/t upper extremity pain with motion|unable to use independently d/t lower extremity weakness"]
Manual Wheelchair: [checkbox value="wheeled by staff|unable to use independently d/t upper extremity weakness|unable to use independently d/t dementia"]
Powered Wheelchair: [checkbox value="Pending Cognitive Ax. |unable to use independently d/t dementia"]
Progression of ambulation difficulty over time: [checkbox value="improving|deteriorating|unchanged"]

ACTIVITIES OF DAILY LIVING
Reports limited activities of daily living d/t: [checklist name="services" value="upper extremity weakness|upper extremity spasticity|lower extremity weakness|lower extremity spasticity|poor standing balance|poor sitting balance|poor coordination|poor endurance evidenced by shortness of breath with exertion|oxygen use|frequent falls|dizziness|Fatigue"]
ADLs requiring the assistance: [checklist name="services" value="Getting in/out of bed|Dressing/undressing|Showering (washing) |Showering (Drying)|Grooming|Transfer between bed, chair, & mobility device|Toileting|Ambulating around the home.|Feeding|Light meal preparation|Complex meal preparation|Light cleaning |Heavy cleaning|Accessing the Community"]
PHYSICAL EXAM
Weight: [text name="Weight"]
Height:[text name="Weight"]
Hip Width: [text name="Weight"]
Shoulder Width: [text name="Weight"]
Shoulder Height: [text name="Weight"]
Lower leg length: [text name="Weight"]
Thigh/buttocks length:[text name="Weight"]
Posture: [checkbox value="Healthy Posture.|Kyphosis Posture.|Flat Back Posture.|Swayback Posture.|Forward Head Posture"]
Tremor: [checkbox value="Yes |No "]
Vision: [checkbox value="grossly intact|wearing glasses"]
Hearing: [checkbox value="grossly intact to conversation|hard of hearing|very HOH|wearing hearing aid"]
Cognition: [checkbox value="A/O x3|able to answer questions without difficulty|unable to answer questions|STML. "]
Neck: [checkbox value="normal exam|decreased ROM|pain with motion"]
Upper Extremity: [checkbox value="normal exam|deformity|impaired strength|decreased range of motion|decreased sensation|contracture|dialysis shunt on left|dialysis shunt on right|edema on left|edema on right"]
Lower Extremity: [checkbox value="normal exam|deformity|impaired strength|decreased range of motion|decreased sensation|contracture|dialysis shunt on left|dialysis shunt on right|edema on left|edema on right"]
Sit to stand transfers:[checkbox value="without difficulty|with significant difficulty|unable to perform independently"]
Gait: [checkbox value="without difficulty|non-ambulatory|shuffling|ataxic|wide|max assist|mod assist|stops every few steps to rest|diaphoresis|tachycardia|tachypnea"]
Skin: [checkbox value="grossly intact|wounds|Dry/flaky skin"]
NARRATIVE:
This is a
[textarea name="variable_1" default="sample text"] y/o patient with several health problems worsening gradually over the past year. The client is experiencing difficulty engaging in their ADL'S safely and independently whilst living at home d/t:[textarea name="variable_1" default="sample text"]. To work towards the client's goals and improve his/her safety and independence OT is recommending:
Date of Ax:
Persons present:
Settting :
Client name:

DOB:
Diagnosis:
Social history:
Supports/services:
Falls History:
Skin Breakdown:
Ambulation:
Maximum distance ambulated independently:
Cane/SPS:
4WF/Walker:
Manual Wheelchair:
Powered Wheelchair:
Progression of ambulation difficulty over time:

ACTIVITIES OF DAILY LIVING
Reports limited activities of daily living d/t:
ADLs requiring the assistance:
PHYSICAL EXAM
Weight:
Height:
Hip Width:
Shoulder Width:
Shoulder Height:
Lower leg length:
Thigh/buttocks length:
Posture:
Tremor:
Vision:
Hearing:
Cognition:
Neck:
Upper Extremity:
Lower Extremity:
Sit to stand transfers:
Gait:
Skin:
NARRATIVE:
This is a
y/o patient with several health problems worsening gradually over the past year. The client is experiencing difficulty engaging in their ADL'S safely and independently whilst living at home d/t:. To work towards the client's goals and improve his/her safety and independence OT is recommending:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.72, 39 form elements, 136 boilerplate words, 8 text boxes, 3 text areas, 2 dates, 22 checkboxes, 4 check lists, 165 total clicks
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