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OccupationalM.I. Therapy Evaluation Patient Last Name, First Name,

Reason for Referral: Precautions:

Level of Assistance:

Patient #


Independent=I; Modified Independent=M; Stand By Assist=SBA; Supervision=S; Contact Guard Assis=CGA; Minimum=Min; Moderate=Mod; Maximum=Max; Dependent=D

Activities of Daily Living (MDS G-1g,h,j,2)

Feeding Grooming UB Bath LB Bath UB Dressing LB Dressing Toileting/Hygiene Homemaking Skills

Level of Assist.


Adaptive Equipment/Positioning: Current Seating

Yes W/C Geri Chair Other Appropriate? Further assessment Other: No

Functional Mobility (MDS G-1a,b, I)

Rolling Supine to Sit Sit to Supine Bed to W/C Toilet Tub/Shower

Level of Assist. Balance (MDS G-3)

Sitting Standing Activity Tolerance: Static Dynamic

ROM and Strength/Voluntary Movement (MDS G-4: A/B) Left

Coordination Tone Strength AROM PROM

Body Part Upper

Shoulder Elbow Wrist Hand


Coordination Tone Strength AROM PROM

Left Upper Extremity Comments:

Right Upper Extremity Comments:

Sensory Integration

Key: I=Intact; Imp=Impaired; A=Absent; NT=Not Tested

Cognitive Function

L R Perception Visual Field Figure-Ground Body Scheme R/L Discrimination R/L Neglect L R Orientation: Follows Commands: Communication: Attention Span: Judgment: Memory: Safety Awareness: Comments: Person One-Step Verbal Place Multi-Step Non-verbal Time Unable None

Sensation Stereognosis Proprioception Sharp/Dull Light Touch Temperature Pain:


Therapist Signature/Credentials/Date: Physician's Name: Patient's Room #



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