SELECT Patient_ID, Last_Name_M0040 AS Last_Name, First_Name_M0040 AS First_Name, Middle_Initial_M0040 AS Middle ,Payer_ID FROM #Request.prefix_db_agency#.patient WHERE Patient_Id = '#session.cs.patientid#' AND Agency_Id = '#session.AgencyId#' SELECT M0650_Assess, Grooming_M0640, Assessment_ID, Start_of_Care_M0030, M0810_Assess, After_Discharge_Services_M0880, Ambulation_M0700p, Bathing_M0670, Bathing_M0670p, Discharged_From_M0175 , Medical_or_Treatment_Change_M0200, Therapies_Home_M0250, Transferring_M0690, High_Risk_Factors_M0290, Hearing_M0400, Freq_of_Pain_M0420, Open_Wounds_M0440, Meal_Prep_M0720p, Bowel_Incont_M0540, Conditions_Prior_M0220, Overall_Prognosis_M0260, Life_Exp_M0280, Vision_M0390, Speech_M0410, Intrac_Pain_M0430, Pressure_Ulcer_M0445, Breathing_M0490, Pressure_Ulcer_a_M0450, Pressure_Ulcer_b_M0450, Pressure_Ulcer_c_M0450, Pressure_Ulcer_d_M0450, Pressure_Ulcer_e_M0450, Pressure_Ulcer_Stage_M0460, Pressure_Ulcer_Status_M0464, Stasis_Ulcer_Num_M0470, Stasis_Ulcer_Hidden_M0474, Stasis_Ulcer_Status_M0476, Surgical_Wound_M0482, Surgical_Wound_OB_M0484, Transport_M0730, Transport_M0730p, Urinary_INcont_when_M0530, When_Anxious_M0580, Patient_Behav_freq_M0620, Psy_Nursing_M0630, Grooming_M0640p, Dress_Lower_M0660, Caregiver_Manage_Equip_M0820, Dress_Upper_M0650p, Cog_Function_M0560, Depressive_Feelings_M0590, Discharge_Disposition_M0870, Dress_Lower_M0660p, Dress_Upper_M0650, Eating_M0710p, Ambulation_M0700, Ambulation_M0700p, Eating_M0710, Emergent_Care_M0830, Housekeeping_M0750p, Inhalant_Meds_M0790, Inhalant_Meds_M0790p, Inject_Meds_M0800, Nursing_Home_M0900, Oral_Meds_M0780p, Inpatient_Facility_M0855, Laundry_M0740, Laundry_M0740p, Rehab_Prognosis_M0270 , Assessment_note, Record_Created_By, Transmission_status FROM #Request.prefix_db_agency#.Assessment_New WHERE Assessment_ID='#session.cs.AssessmentId#' select Last_Name,First_Name from Employee where Employee_ID = '#AssForm.Record_Created_By#'

#DateFormat(AssForm.Start_of_Care_M0030,'mm/dd/yyyy')# - OT Adult Form

Reason For Evaluation

Other Services Involved (By Current Agency)

Other Agencies Involved

Medical Diagnoses

Prior level of functioning

Precautions/Restriction on Weight-Bearing status

ADLs: Physical

Feeding

checked/> 0 - Dependent checked/> 1 - Maximum assist checked/> 2 - Moderate assist checked/> 3 - Minimal assist checked/> 4 - Contact guard checked/> 5 - Stand-by assistance checked/> 6 - Supervision checked/> 7 - Modified Independent checked/> 8 - Independent

ADLS: VERBAL

Feeding

checked/> 0 - Needs cueing checked/> 1 - Independent

Grooming

checked/> 0 - Needs cueing checked/> 1 - Independent

Bathing

checked/> 0 - Needs cueing checked/> 1 - Independent

U/E Dressing

checked/> 0 - Needs cueing checked/> 1 - Independent

L/E Dressing

checked/> 0 - Needs cueing checked/> 1 - Independent

Homemaking

checked/> 0 - Needs cueing checked/> 1 - Independent

DME

checked/> 0 - Needs cueing checked/> 1 - Independent

Toileting

checked/> 0 - Needs cueing checked/> 1 - Independent

Functional/Mobility Transfers

checked/> 0 - Needs cueing checked/> 1 - Independent

UPPER EXTREMITY FUNCTION RIGHT

Grasp Release

checked /> 0 - Dependent checked/> 1 - Maximum assist checked/> 2 - Moderate assist checked/> 3 - Minimal assist checked/> 4 - Contact guard checked/> 5 - Stand-by assistance checked/> 6 - Supervision checked/> 7 - Modified Independent checked/> 8 - Independent

UPPER EXTREMITY FUNCTION LEFT

UPPER EXTREMITY FUNCTION LEFT

Grasp Release

checked/> 0 - Dependent checked/> 1 - Maximum assist checked/> 2 - Moderate assist checked/> 3 - Minimal assist checked/> 4 - Contact guard checked/> 5 - Stand-by assistance checked/> 6 - Supervision checked/> 7 - Modified Independent checked/> 8 - Independent

DOMINANCE

checked /> Right checked /> Left

PERCEPTUAL ORIENTATION (age appropriate)

Apraxia

checked /> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

Right/left Discrimination

checked/> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

Visual Field

checked /> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

Visual Tracking

checked /> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

COGNITION/COMMUNICATION/BEHAVIOR

Orientation

checked/> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

Communication Skills

checked/> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

Safety Awareness

checked /> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

Problem Solving

checked /> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

Medication Management

checked /> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

Financial Management

checked /> 0 - Dependent checked/> 1 - Requires assistance checked/> 2 - independent

SENSATION

Sharp/Dull

checked /> 0 - Absent checked/> 1 - Impaired checked/> 2 - Intact

Stereognosis

checked /> 0 - Absent checked/> 1 - Impaired checked/> 2 - Intact

Position Sense

checked/> 0 - Absent checked/> 1 - Impaired checked/> 2 - Intact

Pain Assessment

EDEMA

Tissue quality

Girth

History of compression use?

History of wounds?

Reason why patient needs equipment