|
Eval/reeval
|
Physician Name
|
|
Date of Stroke
|
Medical Dx
|
|
Recertification Date
|
Referring diagnosis
|
|
Session #
|
Other diagnoses/medical conditions
|
|
Allergies
|
Precautions
|
|
Pain level
|
Medications
|
|
PMHx
|
|
|
Surgical History
|
Other services
|
|
ADLs
|
Specify ADLs if needed
|
|
IADLs
|
Specify IADLs if needed
|
|
Functional Mobility
|
Assisted device
|
|
Home Environment
|
PLOF/Work Hx
|
|
Strength/ROM assessment
|
|
|
Muscle tone
|
Description of muscle tone
|
|
AROM limitations?
|
Description of AROM limitations
|
|
PROM limitations?
|
Describe PROM limitations
|
|
Involuntary movements?
|
Describe Involuntary Movements
|
|
Manual Muscle Strength-R
• • •
|
Location of decreased MMS-R
|
|
Manual Muscle Strength-L
• • •
|
Location of decreased MMS-L
|
|
Balance
|
Describe decreased balance
|
|
Cognition
|
|
|
Level of arousal
|
Oriented to
• • •
|
|
Impulse Control
|
Motivation
|
|
Judgment
|
Initiation
• • •
|
|
Cognitive Flexibility
|
Concept Formation
|
|
Selective attention
|
Sustained attention
|
|
Short term memory
|
Divided attention
|
|
Short term memory
|
Long term memory
|
|
Working memory
|
Ideation
|
|
Safety
|
Understanding social demands
|
|
Transitions
|
|
|
Outcome Measures
|
|
|
VMI administered?
|
VMI %
|
|
VMI Visual Perception %
|
VMI Motor Coordination %
|
|
Barthel
|
Barthel total score (0-20)
|
|
KATZ
|
KATZ total score (0-6)
|
|
QuickDASH
|
QuickDASH score
|
|
Lawton-Brody
|
Lawton-Brody score
|
|
RPE Scale
|
RPE scale
|
|
Assessment
|
|
|
GOALS
|
|
|
Short term goals (2-3 weeks)
|
|
|
Long term goals (30 days)
|
Plan free text
|
|
Occupational Therapy frequency
|
Plan of care
• • •
|
|
Tier level
|
|
