Cognition Orientation
Name
Month
Location
Pen, Park, Black
Pain Level & Location
Covid-19
Weight & Height
Prior Level of Function
Past or Current
Existing Precautions/
Restrictions
Subjective
Chart reviewed. Pt received
seated on living room couch
and was willing to participate
in OT eval.
Occupational Profile
Hobbies
Household Chores
Who they live with:
Familial Help:
DME/AE used at home
AE owned
Fallen in the past year?
# Stairs into the house
Bedroom location
Bathroom location
Type of shower
Current Living
Arrangement
Vision Impairment/
Limitations
Tub/ Walk-in Shower
Curtin/ Door
Glasses?
Visual Field Deficit
Sensory Assessment
RUE:
LUE:
RLE
LLE:
Other sensory feelings
Hearing
Bed Mobility
Supine-Sit
Sit - Supine
Functional Mobility
Bed to Chair transfer
Chair to bed transfer
Sit to Stand transfer
Stand to sit transfer
Dressing
UB
LB
Shoes/ Socks
Grooming/Hygiene
Teeth brushing
Face washing
Dentures
Bathing
Self Feeding
Balance
Static Seated Balance
Static Standing Balance
Activity Tolerance
Use of hearing aids?
Don
Doff
Position
Don
Doff
Position
Don
Doff
Position
Assistance Level:
Position:
Assistance Level:
Position:
Dyspenia
Time Tolerated
MMT
RUE
LUE
RLE
LLE
Right C8 (middle finger flx at
DIP jt)
& T1 (pinky resists adduction)
Left C8 & T1
Shoulder:
Elbow:
Wrist:
Fingers:
Gross:
Shoulder:
Elbow:
Wrist:
Fingers:
Gross:
Hip:
Knee:
Ankle:
Gross:
Hip:
Knee:
Ankle:
Gross:
C8
T1
C8
T1