"Occupational Therapy Clinic Evaluation Form - Health180"

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Phone 860-848-4180
Fax 860-848-3471
Occupational Therapy Clinic Evaluation—B-3
Initial Evaluation 
Reevaluation 
Name: ___________________________________
DOB: _____________ Date: __________________
Pertinent History: _______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Previous Treatment: _____________________________________________________________________
______________________________________________________________________________________
Personal Concerns/Goals:
1.
4.
2.
5.
3.
6.
Sleep Cycle:
 Sleeps soundly
 Difficulty settling
 Wakes unsettled
 Night terrors
 Restless sleep
 Intermittent waking
 other ________________________
# of hours asleep in 24 hr. cycle_____
Duration of naps__________
Comments: ________________________________________________________________________________________
__________________________________________________________________________________________________
Nutritional Intake:
 Breast fed
 Pump/bottle
 Formula
Comments: ________________________________________________________________________________________
__________________________________________________________________________________________________
Postural Alignment/Symmetry
Report of discomfort/specific areas
Degree of discomfort, 0 (none) – 10 (significant)
Muscle Strength
Muscle Tone
5 (max resistance)
-3 Severe hypotonia
Range of Motion
1 (no resistance)
0 Normal muscle tone
+3 Severe hypertonia
WFL
Impaired
5
4
3
2
1
-3
-2
-1
0
+1
+2
+3
.docx
C:\Users\ronw.SECONNMFG\Desktop\Clinic OT Eval Form Todd Ped
Page 1 of 4
rev: 12/16/2008
Phone 860-848-4180
Fax 860-848-3471
Occupational Therapy Clinic Evaluation—B-3
Initial Evaluation 
Reevaluation 
Name: ___________________________________
DOB: _____________ Date: __________________
Pertinent History: _______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Previous Treatment: _____________________________________________________________________
______________________________________________________________________________________
Personal Concerns/Goals:
1.
4.
2.
5.
3.
6.
Sleep Cycle:
 Sleeps soundly
 Difficulty settling
 Wakes unsettled
 Night terrors
 Restless sleep
 Intermittent waking
 other ________________________
# of hours asleep in 24 hr. cycle_____
Duration of naps__________
Comments: ________________________________________________________________________________________
__________________________________________________________________________________________________
Nutritional Intake:
 Breast fed
 Pump/bottle
 Formula
Comments: ________________________________________________________________________________________
__________________________________________________________________________________________________
Postural Alignment/Symmetry
Report of discomfort/specific areas
Degree of discomfort, 0 (none) – 10 (significant)
Muscle Strength
Muscle Tone
5 (max resistance)
-3 Severe hypotonia
Range of Motion
1 (no resistance)
0 Normal muscle tone
+3 Severe hypertonia
WFL
Impaired
5
4
3
2
1
-3
-2
-1
0
+1
+2
+3
.docx
C:\Users\ronw.SECONNMFG\Desktop\Clinic OT Eval Form Todd Ped
Page 1 of 4
rev: 12/16/2008
Comments:
Postural Strength:
supine flexion __________seconds
prone extension __________seconds
scoliosis
kyphosis
lordosis
facilitated segment__________________________
Comments:
Reflexes
Protective Extension
N = No Apparent Deficit
ATNR
Forward
P = Partial Deficit
S = Severe Deficit
STNR
Backward
NE = Not Examined
NO = Not Observed
Righting Rxns
Right
Equilibrium Rxns
Left
Upper Extremity Coordination: (Proprioceptive Functions)
Slow Movements
Thumb Finger Sequencing
Forearm Rotation
Finger to Nose
Comments:
Oculomotor/Functional Visual Skills
Fixation
Convergence
Visual Attention
Divergence
Tracking/Pursuits
Eye Contact
Saccades
1◦ Visual Field
(peripheral or central)
Lateral Rotation on fixed visual point
Comments:________________________________________________________________________________
_________________________________________________________________________________________
Neurological Processing:
Attention
Arousal/Alertness
.docx
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Vestibular
Proprioceptive
Tactile
Auditory
Visual
Olfactory
Oral
Social/Emotional
Motor Planning/Praxis:
Oral Motor/Feeding:
Ideation
Drooling
Food/Liquid Spillage
Planning/Execution
Lip Closure
Mouth/Tongue Posture
Comments: __________________
Straw Sucking
Intelligibility
___________________________
Chewing
Food Aversions
(temperature, texture, taste)
Drinking
Aversion to Toothbrushing
Blowing Bubbles
Comments:
Fine Motor/Perceptual:
Hand dominance
____ right
____ left
____ mixed
____Grasp patterns
____ In-hand Manipulation
____ Scissor skills
____Tool use
____ Fasteners
____ Pre-writing/writing
____ Bilateral coordination/crossing midline
____ Copying 2D/3D objects
____ Right/left discrimination
____Puzzles
____ Identify/match objects
Interpretation/Summary
.docx
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Diagnosis:
Plan of Care:
Frequency & Duration: __________________________________________________
 Excellent
 Good
 Fair
Potential for Progress:
Goals
:
____ Decrease pain
Improve functional performance (i.e., ADL’s/self care, vocational/school, leisure/play)
____
Improve postural control
____
Improve upper extremity function (i.e., strength, range, coordination)
____
Improve oculomotor/functional visual skills
____
Improve ability to self regulate
____
Improve neurological processing (i.e., vestibular, tactile, auditory, visual, olfactory, oral)
____
Improve social participation
____
Improve fine motor/perceptual skills
____
Other
____
Treatments:
Manual therapy (i.e., Craniosacral, NDT, acupressure, etc.)
____
Neuro-motor/processing
____
Fine motor activities
____
Visual motor/perceptual
____
Oral motor/feeding
____
Motor coordination/gross motor
____
Activities of daily living
____
Other
____
Therapist Signature: ________________________________________
Date:_________________
Physician Signature: ________________________________________
Date: _________________
.docx
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