Get the free Occupational Therapy Patient History Form - Stony Brook ...

Occupational and Physical Therapy No Pain Huge Gain! Patient Intake Date: Email Address: Patient Name: LastFirstMiddleSSNMailing Address: StreetCityZipHome Phone: Cell Phone: Work Phone: Occupation:

How to fill out occupational therapy patient history

How to fill out occupational therapy patient history

1. Gather necessary information about the patient such as personal details, medical history, and current medications.
2. Start by filling out the demographic information including the patient's name, age, address, and contact details.
3. Document the reason for seeking occupational therapy and the specific concerns or challenges the patient is facing.
4. Include a comprehensive medical history, noting any previous injuries, surgeries, or underlying medical conditions.
5. Record the patient's current medications, dosage, and frequency of use.
6. Assess the patient's activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as bathing, dressing, meal preparation, and driving.
7. Document the patient's cognitive abilities, including memory, attention, problem-solving skills, and judgment.
8. Evaluate the patient's sensory integration and motor skills, noting any difficulties or impairments.
9. Include the patient's goals and expectations for therapy, as well as any previous therapy experiences.
10. Conclude the occupational therapy patient history by summarizing the findings and providing recommendations for further evaluation or treatment.

Who needs occupational therapy patient history?

1. Individuals who are seeking occupational therapy services.
2. Patients who have experienced injuries or surgeries that impact their ability to perform daily tasks.
3. People with chronic conditions or disabilities that affect their independence and functional abilities.
4. Individuals with cognitive impairments or sensory processing disorders.
5. Individuals with neurological conditions such as stroke, traumatic brain injury, or multiple sclerosis.
6. Children with developmental delays or learning disabilities.
7. Patients who have undergone amputations or have prosthetic limbs.

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What is occupational therapy patient history?

Occupational therapy patient history is a comprehensive record of a patient's past medical treatments, conditions, lifestyles, and any relevant personal information that helps therapy practitioners understand the patient's needs and tailor their therapy.

Who is required to file occupational therapy patient history?

Occupational therapists and healthcare professionals involved in a patient's care are required to file occupational therapy patient history to ensure continuity of care and accurate assessment.

How to fill out occupational therapy patient history?

To fill out occupational therapy patient history, one should gather relevant patient information including medical history, occupational history, current medications, and any personal goals for therapy. This information should be recorded in a structured format, usually provided by the occupational therapy practice.

What is the purpose of occupational therapy patient history?

The purpose of occupational therapy patient history is to collect essential information that aids therapists in developing effective treatment plans, understanding the patient's background, and monitoring progress.

What information must be reported on occupational therapy patient history?

Information that must be reported includes patient demographics, medical history, current symptoms, medications, prior therapy experiences, functional limitations, and personal goals for therapy.