Occupational Therapy Screening Assessment

Personal details

Name

/ Carefirst ID:

Address

/ Tel:
Post Code / Mobile:

Email

Date of birth

/ Ethnic background

Emergency contact

/ Name:
Relationship: / Tel:

Advocate

/
Tel:

Family doctor

/
Tel:
Reason for referral / Reason:
Referred by: / Date of referral:
Person’s view of what could help them:

Verbal Consent

/ The Occupational Therapy Services sits within the Adult Social Care department of Southwark Council. The information that you provide is accessible to other people within Social Care. All information is treated as confidential
Are you happy for the information you give us to also be shared with other people outside of Adult Social Care and /or for us to request information from other agencies/professionals if required.
☐Yes ☐No ☐Yes but with limitations (specify):

Capacity

/ Do you have any reason to doubt this person’s capacity to agree to this assessment?
☐Yes ☐No ☐Don’t know
Communication& Cognition / Language (specify):
Hearing:
Vision:
Memory:
Physical or mental impairment or illness & medical history / Medication and current treatments:
Height: / Weight:
Does the person have a physical, mental impairment or illness for eligibility purposes
☐Yes ☐No
Falls / ☐No history of falls ☐Risk or fear of falls
History of falls: ☐Indoors ☐Outdoors
Date last fall:
Reason:
Frequency:
Pendant alarm in place ☐Yes ☐No
Current situation
Agencies/support networks involved / Start date / Named person
Carers
(if relevant) / Main carer: ☐Informal ☐Formal
Is a universal carer’s assessment required?
☐Yes ☐No ☐Declined ☐Not established
Household structure / Lives alone: ☐Yes ☐No
Other people living at the property:
Environmental details
Tenure / ☐LBS ☐Owner Occupier ☐Private Landlord☐Housing Association
☐City of London
Landlord/HA contact details:
Have you applied for rehousing? ☐Yes ☐No
Reference number:
Layout of property / ☐House ☐Flat ☐Maisonette ☐Bungalow
Property layout
Front access:
Rear access:
Ground floor:
First floor:
Upper floors:
Functional ability
  1. Able to achieve without assistance (but could include the use of equipment / adaptations)
  2. Able to achieve without assistance but it takes significantly longer that would be expected
  3. Able to achieve without assistance but causing significant pain, distress, anxiety
  4. Able to achieve without assistance but (likely) to endanger health or safety of self or others
  5. Only able to achievewith assistance
  6. Not able to achieve, even with assistance

Nutrition
1 / 2 / 3 / 4 / 5 / 6
Holding cutlery
Holding cup
Preparing food
Personal hygiene
1 / 2 / 3 / 4 / 5 / 6 / Bath ☐metal ☐plastic &/ or ☐shower
Getting in/down
Getting up/out
Turning taps
Washing
Drying
Shaving
Cleaning teeth
Clipping nails
Managing hair
Toileting needs
Continence issues ☐urinary ☐faecal
1 / 2 / 3 / 4 / 5 / 6 / Toilet height:
Getting on
Getting off
Managing clothes
Wiping self
Dressing
1 / 2 / 3 / 4 / 5 / 6
Upper body
Lower body
  1. Able to achieve without assistance(but could include the use of equipment / adaptations)
  2. Able to achieve without assistance but it takes significantly longer that would be expected
  3. Able to achieve without assistance but causing significant pain, distress, anxiety
  4. Able to achieve without assistance but (likely) to endanger health or safety of self or others
  5. Only able to achieve with assistance
  6. Not able to achieve, even with assistance

Using the home safely
1 / 2 / 3 / 4 / 5 / 6
Indoor mobility
Manage stairs
Getting on bed
Getting off bed
Lie to sit
Getting on chair
Getting off chair
Maintaining a habitable home
1 / 2 / 3 / 4 / 5 / 6
Housework
Shopping
Laundry
Using appliances
Managing money
Access and engage in work, training, education or volunteering
Interests: / 1 / 2 / 3 / 4 / 5 / 6
Access and use services in local community
1 / 2 / 3 / 4 / 5 / 6 / ☐Blue Badge ☐Taxi card ☐Dial a ride
Outdoor mobility
Public transport
Other
1 / 2 / 3 / 4 / 5 / 6
Caring for a child
Personal/family relationships

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OT screening assessment form June 2015 _ trial form _ V3updated 19/08/2015

Summary
What is the problem? / Functional area
(specified outcomes) / Action proposed / taken
0 /
0 /
0 /
0 /
0 /
0 /
0 /
Well being
Is there likely to be a significant impact on well being (either in one area or through the cumulative effect of the impact on a number of the areas of wellbeing) if the outcomes are not achieved? / 0
0

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OT screening assessment form June 2015 _ trial form _ V3updated 19/08/2015

Informationadvice providedand onward referrals
Date / Info/advice provided / Specific details
Any other info
OT screening assessment conducted
☐by phone ☐face to face ☐on line
If the OT screeningassessment was conducted over the phone the information recorded is solely based on the information / description given by the service user (or other person as specified below) on how they are managing everyday living tasks.
Completed with ☐Service user
☐Other: Contact number:
Date / Completed by
Was home visit required? / ☐yes ☐no
Present on visit / Begin / End

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OT screening assessment form June 2015 _ trial form _ V3updated 19/08/2015