Client name: Sex: M F DOB: Address: Phone No: Clinician: Agency: Date: MEDICAL HISTORY Dx/prognosis: Height: Weight: EQUIPMENT CURRENTLY USED PHYSICAL STATUS Skin history/integrity (note areas of present and past breakdown): Spasticity/tremor (note when it occurs, how it affects function): Upper limb function: Lower limb function: Balance/trunk control (static and dynamic): Period of Use: Sitting posture: FUNCTIONAL STATUS Mobility: Ambulation status: Mobile shower/commode chair use: Independent Assisted Dependent Style: Large front wheel drive Large rear wheel drive Transit Comments: Period of Use: Transfers: Equipment/aids currently used: Floor surface: Bed height: Comments:
Client name: Sex: M F DOB: Address: Phone No: Clinician: Agency: Date: MEDICAL HISTORY Dx/prognosis: Height: Weight: EQUIPMENT CURRENTLY USED PHYSICAL STATUS Skin history/integrity (note areas of present and past breakdown): Spasticity/tremor (note when it occurs, how it affects function): Upper limb function: Lower limb function: Balance/trunk control (static and dynamic): Period of Use: Sitting posture: FUNCTIONAL STATUS Mobility: Ambulation status: Mobile shower/commode chair use: Independent Assisted Dependent Style: Large front wheel drive Large rear wheel drive Transit Comments: Period of Use: Transfers: Equipment/aids currently used: Floor surface: Bed height: Comments:
mobile-shower-commode-chair-assessment-form.docx