seatingmobilityevaluation-catea（12页）.docVIP

Seating/Mobility Evaluation PATIENT INFORMATION: Name: Date seen: DOB: Sex: Address: Physician: Phone: Seating Therapist: Phone: Phone: Primary Therapist: Phone: Referred by: (If other than MD) Insurance/Payor: Recipient#: Equipment Supplier Company: Contact person: Phone: Caregiver name: Phone number: Reason for Referral Patient Goals: Caregiver goals and specific limitations that may effect care: MEDICAL HISTORY: Diagnosis: ICD9 Code: Diagnosis: ICD9 Code: Diagnosis: ICD9 Code: Diagnosis: ICD9 Code: Diagnosis: ICD9 Code: Diagnosis: ICD9 Code: Diagnosis: ?Progressive Disease ?Osteoporosis Recent/future surgeries/prognosis: Height: Weight: Explain recent changes or trends in weight: History: Cardio Status: Functional Limitations: ?Intact ? Impaired Respiratory Status: Functional Limitations: ?Intact ?Impaired Orthotics: HOME ENVIRONMENT: ?House? Condo/town home ?Apartment ?Asst Living ?LTCF ?own ?rent ?Lives Alone ? Lives with Others Hours without caregiver: Entrance: ?Level ?Stairs ?Ramp ?Lift Width of entrance: Number of floors: ?Accessible Bedroom ?Accessible Bathroom Narrowest Doorway to access: Non-accessible rooms: Storage of Wheelchair: COMMUNITY ADL: TRANSPORTATION: ?Car ?Van ?Bus ?Adapted w/c Lift ? Ambulance ?Other: Where is w/c stored during transport? Size of area needed for transport of w/c w x d x h: ?Self Driver Drive while in Wheelchair ?yes ?no Tie Downs: Van head clearance: Door _____” Inside _____” Van door width ______” Ramp lift w ____” x d _____” Employment: #Hours per day/specific requirements pertaining to mobility School: #Hours per day/specific requirements pertaining to mobility Other FUNCTIONAL/SENSORY PROCESSING SKILLS: Handedness: ?Right ?Left Comments: Functional Processing Skills fo