| System |
| UnitID |
1 |
1 |
| Date |
2001/5/14 |
2001/5/14 |
| Started |
13:58 |
14:29 |
| Finished |
14:29 |
14:54 |
| Client |
| Surname |
Lake |
Arnold |
| GivenName |
Ruth |
Luke |
| Gender |
Female |
Male |
| DateofBirth |
8-6-37 |
17-2-76 |
| Address |
6 Poole St, Ardross.Perth. WA |
34 Mend St, Geraldton. Perth. W.A. |
| PhoneContact |
(08) 96789432 |
(08) 92345676 |
| MaritalStatus |
Single, |
Single, |
| LiveWith |
Alone, |
Alone, |
| Accomodation |
Unit,Rental, |
Flat,Rental, |
| PreferredLanguage |
English |
English |
| AssessmentLocation |
Rehab Facility, |
Rehab Facility, |
| AssessorContact |
Helen Deans. O.T. (08) 5678934 |
Jack Hardy(08) 9876547 |
| Medical History |
| DrGP |
Dr Louise Carter |
Dr Greg Gray |
| DrContact |
(08) 97654334 |
(08) 96421359 |
| Diagnosis |
Joint Replacement, |
Amputee, |
| DiagnosisOther |
Right Hip |
Right above-elbow amputee |
| Disability |
Muscle weakness & decreased range |
Loss of dominant right hand |
| Medication |
Analgesics,Anti-Coagulants, |
Analgesics, |
| MedicationOther |
|
|
| SpecialisedTreatments |
|
Scar Management,Prosthesis/Training, |
| MedicalNotes |
Weight-bearing with cruches |
Wound healing well |
| Locomotion |
| Walking |
Yes |
Yes |
| Wheelchair |
No |
N/A |
| StepsStairs |
No |
Yes |
| LocomotionAids |
Crutches, |
|
| AidOther |
|
|
| Orthosis |
|
|
| Prosthesis |
|
Yes |
| LocomotionStatus |
Safe |
Safe |
| Wh/Chair Skills |
| Slopes |
|
|
| RoughGround |
|
|
| Kerbs |
|
|
| Step |
|
|
| RearWheelBalance |
|
|
| TransferWhChintoCar |
|
|
| Transfers |
| BedMobility |
Independent, |
Independent,Independent,Assistive Devices, |
| ChairWheelchair |
Independent, |
|
| Bed |
Independent, |
Independent,Assistive Devices, |
| BathShower |
Needs Assistance, |
Independent,Assistive Devices, |
| Toilet |
Independent, |
Independent,Assistive Devices, |
| Car |
Needs Assistance, |
Independent, |
| FloorChair |
|
Needs Assistance |
| Bathing |
| Bath |
Needs Assistance, |
Independent,Assistive Devices, |
| Shower |
Needs Assistance, |
Independent,Assistive Devices, |
| Personal Hygiene |
| Toileting |
Needs Assistance, |
Independent,Assistive Devices, |
| BladderBowel |
Bladder/Continent,Bowel/Continent, |
Bladder/Continent,Bowel/Continent, |
| Grooming |
| Haircare |
Independent, |
Independent,Assistive Devices, |
| CleanTeeth |
Independent, |
Independent, |
| Shave |
Independent, |
Independent, |
| ApplyMakeup |
|
|
| Nailcare |
Independent, |
Needs Assistance, |
| Dressing |
| UpperLimb |
Independent, |
Needs Assistance,Assistive Devices, |
| LowerLimb |
Needs Assistance,Assistive Devices, |
Independent, |
| Fastenings |
Needs Assistance |
Needs Assistance |
| Eating |
| Eating |
Independent, |
Independent,Assistive Devices, |
| Drinking |
Independent, |
Independent,Assitive Devices, |
| ChewSwallow |
Independent, |
Independent, |
| Services |
| AlliedHealth |
Occup/Therapy,Physiotherapy, |
Occup/Therapy,Physiotherapy,Nursing, |
| OtherAlliedHealth |
|
|
| LiveinCommunity |
Yes |
Yes |
| Carer |
Yes |
Yes |
| CarerMaintainSupport |
Yes |
Yes |
| CommunitySupport |
Home-visit, |
Transport,Home-visit, |
| CommunityFacilities |
|
|
| ResidentialCare |
|
|
| ResidentialCareOther |
|
|
| Notes |
O.T. to supply assistive devices |
Motivated for prosthesis training |