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 Assessment_ID, Start_of_Care_M0030, After_Discharge_Services_M0880, Ambulation_M0700, Ambulation_M0700p, Bowel_Incont_M0540, Therapies_Home_M0250, Hearing_M0400, Speech_M0410, Freq_of_Pain_M0420, Intrac_Pain_M0430, Pressure_Ulcer_M0445, Open_Wounds_M0440, Overall_Prognosis_M0260, Transferring_M0690p, Life_Exp_M0280, High_Risk_Factors_M0290, Vision_M0390, Pressure_Ulcer_a_M0450, Pressure_Ulcer_b_M0450, Pressure_Ulcer_e_M0450, Pressure_Ulcer_Stage_M0460, Pressure_Ulcer_c_M0450, Pressure_Ulcer_d_M0450, Inject_Meds_m0800p, Pressure_Ulcer_Status_M0464, Breathing_M0490, Stasis_Ulcer_Num_M0470, Stasis_Ulcer_Hidden_M0474, Stasis_Ulcer_Status_M0476, Surgical_Wound_M0482, Caregiver_Manage_Equip_M0820, Cog_Function_M0560, Conditions_Prior_M0220, Depressive_Feelings_M0590, Discharge_Disposition_M0870, Eating_M0710, Eating_M0710p, Emergent_Care_M0830, Emergent_Care_Reason_M0840, Endocrine_Assess, Home_Safety_Assess, Hospice_Assess, Hospital_Reason_List_M0895, Hospital_Reason_M0890, Housekeeping_M0750, Housekeeping_M0750p, Inhalant_Meds_M0790, Inhalant_Meds_M0790p, Inject_Meds_M0800, Inpatient_Facility_M0855, Laundry_M0740, Laundry_M0740p, M0250_Assess, M0420_Assess, Pain1, Pain2, Pain3, Pain4, Pain5, M0440_Assess, M0490_Assess, M0520_Assess, M0540_Assess, M0550_Assess, M0610_Assess, M0650_Assess, M0810_Assess, Meal_Prep_M0720, Meal_Prep_M0720p, Medical_or_Treatment_Change_M0200, Nursing_Home_M0900, Oral_Meds_M0780, Oral_Meds_M0780p, Ostomy_for_Bowel_M0550, Patient_Behav_freq_M0620, Patient_Behav_Weekly_M0610, Patient_Manage_Equip_M0810, Resp_Treatments_M0500, Shopping_M0760, Shopping_M0760p, Stasis_Ulcer_M0468, Surgical_Wound_Hidden_M0486, Surgical_Wound_OB_M0484, Surgical_Wound_Status_M0488, Therapy_Need_M0825, Toileting_M0680p, Transferring_M0690, Transport_M0730, Transport_M0730p, Urinary_INcont_M0520, Urinary_INcont_when_M0530, Use_Phone_M0770, Use_Phone_M0770p, UTI_M0510, When_Anxious_M0580, Psy_Nursing_M0630, Grooming_M0640, Grooming_M0640p, Dress_Upper_M0650, Dress_Upper_M0650p, Dress_Lower_M0660p, Bathing_M0670, When_Confused_M0570, Discharged_From_M0175, Bathing_M0670p, Toileting_M0680, 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 #Request.prefix_db_lookup#.Employee where Employee_ID = '#AssForm.Record_Created_By#' pat = CreateObject("Component", "assessment"); get_pain_que = pat.get_pain_ques('1 - Start of care - further visits planned','pain');

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

Reason For Evaluation

Other Services Involved (By Current Agency)

Other Agencies Involved

Medical Diagnoses

Chair-Wheelchair

checked/> 0 - Dependent checked/> 1 - Max assist checked/> 2 - Mod assist checked/> 3 - Min assist checked/> 4 - Contact guard assist checked/> 5 - Standby assist checked/> 6 - Supervision checked/> 7 - Modified independent checked/> 8 - Independent

Bath-Shower

checked/> 0 - Dependent checked/> 1 - Max assist checked/> 2 - Mod assist checked/> 3 - Min assist checked/> 4 - Contact guard assist checked/> 5 - Standby assist checked/> 6 - Supervision checked/> 7 - Modified independent checked/> 8 - Independent

TO BE ASSESSED BY OT

Sits up and maintains balance

checked/> 0 - Dependent checked/> 1 - Max assist checked/> 2 - Mod assist checked/> 3 - Min assist checked/> 4 - Contact guard assist checked/> 5 - Standby assist checked/> 6 - Supervision checked/> 7 - Modified independent checked/> 8 - Independent

Balance OR Gail Tests

Berg Score value="#AssForm.Pressure_Ulcer_c_M0450#" />

Tinetti Score value="#AssForm.Pressure_Ulcer_d_M0450#" />

TUG Test value="#AssForm.Inject_Meds_m0800p#" />

MUSCLE STRENGTH

Range Of Motion

Elbow

Flexion - PROM - Right :

Flexion - PROM - Left :

Flexion - AROM - Right :

Flexion - AROM - Left :

Hyperextension - PROM - Right :

Hyperextension - PROM - Left :

Hyperextension - AROM - Right :

Hyperextension - AROM - Left :

Pronation - PROM - Right :

Pronation - PROM - Left :

Pronation - AROM - Right :

Pronation - AROM - Left :

Supination - PROM - Right :

Supination - PROM - Left :

Supination - AROM - Right :

Supination - AROM - Left :

Shoulder

Flexion - PROM - Right :

Flexion - PROM - Left :

Flexion - AROM - Right :

Flexion - AROM - Left :

Abduction - PROM - Right :

Abduction - PROM - Left :

Abduction - AROM - Right :

Abduction - AROM - Left :

Hip

Flexion - PROM - Right :

Flexion - PROM - Left :

Flexion - AROM - Right :

Flexion - AROM - Left :

Abduction - PROM - Right :

Abduction - PROM - Left :

Abduction - AROM - Right :

Abduction - AROM - Left :

Internal Rotation - PROM - Right :

Internal Rotation - PROM - Left :

Internal Rotation - AROM - Right :

Internal Rotation - AROM - Left :

External Rotation - PROM - Right :

External Rotation - PROM - Left :

External Rotation - AROM - Right :

External Rotation - AROM - Left :

Knee

Flexion - PROM - Right :

Flexion - PROM - Left :

Flexion - AROM - Right :

Flexion - AROM - Left :

Extension - PROM - Right :

Extension - PROM - Left :

Extension - AROM - Right :

Extension - AROM - Left :

Ankle

Flexion - PROM - Right :

Flexion - PROM - Left :

Flexion - AROM - Right :

Flexion - AROM - Left :

Extension - PROM - Right :

Extension - PROM - Left :

Extension - AROM - Right :

Extension - AROM - Left :

Cervical_Spine

Flexion - PROM - Right :

Flexion - PROM - Left :

Flexion - AROM - Right :

Flexion - AROM - Left :

No Pain Pain Assessment Pain assessment incomplete

Reason why patient needs devices value="#AssForm.Toileting_M0680#" >