Md. Mostafizur Rahman

physiotherapy assessment ® Resident’s Name: DOB: Room No. : ........................ Date of Admission: ...................... Medical History: .................................................................................................. ...................................................................................................................... ...................................................................................................................... Hearing: select Notes:............................. Vision: select Notes:............................. Speech: select Notes:.................. Comprehension: select Notes:............................. Cognitive Status (at time of assessment): ................................................................... ...................................................................................................................... number of staff transfers equipment details/comments Please Select Rolling Please Select Bridging Up/Down bed Please Select Supine to sitting Please Select Please Select Please Select Please Select Sit to stand Please Select Please Select Chair to chair Please Select Mobility: Colour Classification:................ Mobility Aid:........................................... Ambulation: Assistance: ................................................................................... Gait: ................................................................................... Functional Measure: ............................ Exercise Tolerance: ...................... Balance: Sitting: Required Seating: Standing: .................................................................................. ................................................................................. .................................................................................. Outcome Measure:.................. .................. Functional Outcome: .................... Falls Risk: Select FRAT: please refer to FRAT Falls History: ...................................................................................................... Cardiothoracic Status: ........................................................................................... Initial: ..... - Page 1 of 3 - - physiotherapy assessment Resident’s Name: DOB: Limb Assesment (consider impact on function) ROM (hand behind back) UL STRENGTH / TONE DEXTERITY/GRIP/CO-ORDINATION ROM LL STRENGTH / TONE Pain Assessment Details of pain (include body chart and pain score) Agg: ............................ Ease:............................ How does the pain limit function or impact lifestyle? Observations and additional information: Oedema: ..................................................... Skin Integrity: ............................................... Sensation: UL: select LL: select Notes (footwear): ................................................................................................ Name: ................................................. Signature: .............................................. Date: .................................................. Designation: Physiotherapist Review Date: ....................... Review Date: ....................... Review Date: ....................... Physiotherapist: ....................... Physiotherapist: ....................... Physiotherapist: ....................... Signature: Signature: Signature: ....................... ....................... - Page 2 of 3 - ......................- physiotherapy careplan ® Resident’s Name: DOB: This careplan is to be implemented with staff assistance each day unless otherwise stated. FALLS/INJURY PREVENTION STRATEGIES RECOMMENDED Falls Risk: Select FRAT: refer to FRAT SEATING REQUIREMENTS Details: ....................................................................................................... MOBILITY Please Select Colour Classification: ................................... Mobility Aid: ................................... Assistance: ................................................................................................... Distance: ................... Frequency: ..................................... SIT TO STAND PRACTICE Details: Please Select ......................................................................... Please Select PERSONAL EXERCISES - in addition to regular mobility as outlined above, refer to personalised exercise sheet. EXERCISE GROUPS Details:........................................................................................................ COMPLEX HEALTH CARE DIRECTIVES & ADDITIONAL CARE care requirement details Please Select Please Select Please Select Please Select Name: ................................................. Signature: .............................................. Date: .................................................. Designation: Physiotherapist Review Date: ....................... Review Date: ....................... Review Date: ....................... Physiotherapist: ....................... Physiotherapist: ....................... Physiotherapist: ....................... Signature: Signature: Signature: ....................... ....................... - Page 3 of 3 - ......................-