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Eval/reeval
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Time In
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Time Out
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Referral source
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Referring diagnosis
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Pediatrician
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Other diagnoses/medical conditions
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Allergies
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Precautions
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Birth History
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Medications
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Surgical History
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Other services
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Home Environment
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Developmental History
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COPM
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COPM problem list
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Reflexes
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Muscle tone
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Description of muscle tone
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AROM limitations?
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Description of ROM limitations
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PROM limitations?
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Describe involuntary movement
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Involuntary movements?
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Manual Muscle Strength
• • •
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Location of decreased MMS
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Functional gait pattern
• • •
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Describe decreased gait pattern
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Balance
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Describe decreased balance
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Cardiovascular system function
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Describe decreased hematological
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Hematological function
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Describe decreased cardio
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Immunological function
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Describe immunological deficit
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Respiratory function
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Describe respiratory deficits
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Nerve integrity
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Describe nerve integrity deficit
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Body structure variation?
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Describe body structure variatio
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Level of arousal
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Posture
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Energy level
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Oriented to
• • •
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Impulse Control
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Motivation
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Coping skills
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Appetite
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Judgment
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Behavioral regulation
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Cognitive Flexibility
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Concept Formation
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Selective attention
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Sustained attention
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Short term memory
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Divided attention
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Working memory
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Long term memory
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Understanding object properties
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Mental functions of movement
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Ideation
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Understanding social demands
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Safety
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Transitions
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Short term memory
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WeeFIM administered?
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WeeFIM Grooming
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WeeFIM Upper Body Dressing
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WeeFIM Bowel Management
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WeeFIM Lower Body Dressing
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WeeFIM Bladder Management
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WeeFIM Eating
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WeeFIM Bathing
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Sensory Profile administered?
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Oral Processing
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Visual processing
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Auditory Processing
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Olfactory processing
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Tactile processing
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Proprioception processing
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Vestibular processing
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Pain processing
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Temperature processing
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Pressure processing
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Low Registration
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Sensation Seeking
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Sensory Sensitivity
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Sensation Avoiding
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Low Threshold
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Emotionally Reactive
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Low Endurance/Tone
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Oral Sensory Sensitivity
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Inattention/Distracibility
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Poor Registration
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Sedentary
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Fine motor/Perceptual
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Sensory Processing/Endurance/Tone
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Modulation/Body position/Movement
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Modulation/Movement/Activity
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Modulation/Sensory/Emotion
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Modulation/Visual/Emotional/Activity
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Emotional/Social responses
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Behavior/Sensory
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Items Indicating Threshold for Response
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Describe sensory differences
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PDMS administered?
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PDMS Fine Motor Z Score
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PDMS FM Standard Scores
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PDMS Gross Motor Z Score
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PDMS GM standard score
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PDMS Total Motor Z Score
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VMI administered?
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VMI %
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VMI Visual Perception %
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VMI Motor Coordination %
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BOT-2
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Strength and Agility Standard Score
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Fine Manual Control Standard Score
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Manual Coordination Standard Score
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Body Coordination Standard Score
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FEAS results
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FEAS administered?
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Greenspan results
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Greenspan administered?
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BRIEF-2 Parent administered?
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BRIEF-2 Teacher administered?
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Inhibit
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Self Monitor
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Shift
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Emotional Control
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Initiate
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Working Memory
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Plan/Organize
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Task Monitor
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Organization of Materials
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Behavior Regulation Index
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Emotional Regulation Index
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Cognitive Regulation Index
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Global Executive Composite
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Assessment free text
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Factors supporting participation
• • •
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Factors hindering participation
• • •
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Areas of Successful Occupation
• • •
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Decreased participation in
• • •
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Performance risks include
• • •
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Rehabilitation potential is
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Treatment indicated?
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Occupational Therapy frequency
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Duration
|
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Plan of care includes
• • •
|
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Short term goals
|
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Long term goals
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Plan free text
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Discharge Plan
|
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MD Signature
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Printed name of MD
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Date of MD signature
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