Manual Electric Recliner Chair

Document Sample
Manual  Electric Recliner Chair Powered By Docstoc
					Surname:

Given Name: File No. Manual / Electric Recliner Chair Assessment Form File No. Surname: Card Type: Gold White

Date Of Birth: ___/___/___ Rehabilitation Appliances Program PO Box 87A Melbourne 3001 Phone: (03) 9284 6000 Fax: (03) 9284 6796 Occupational Therapist Name: Organisation: Address: Phone: Given Name: Address Phone: Please indicate when available Monday: Tuesday: am/pm Thursday: am/pm Friday:

am/pm am/pm

Wednesday: am/pm Fax:

(Please circle)

Signature:......................................................................... Date:____/____/____ Source of Referral: Phone: MANUAL / ELECTRIC RECLINER CHAIR ASSESSMENT FORM : APRIL 2004 Social Situation: Living in: Lives Alone: House / Unit: L.M.O. Phone: Accompanied: Retirement Village: Hostel:

Carer’s General Health: (If applicable)

Relevant Medical History / Prognosis:

Height: Functional Status: Mobility (equipment used & distance):

Weight:

Upper Limb Function (dexterity, strength, co-ordination):
Page 1

Surname:

Given Name:

File No.

Functional Status (continued): Lower Limb Function (range of movement, strength, balance): Physio Therapy strengthening / maintenance program recieved / arranged? Other comments (e.g. cognition):

Transfers: Height (cm) Car: Toilet: Bed: Shower Seat: Dining Chair: ....................... ....................... ....................... ....................... ....................... Yes No Independent Aids Used Assisted

*

*Is Veteran / War Widow currently driving? Current Seating: Describe style: Condition Height Is existing seating contributing to functional difficulties? Could veteran / war widow transfer from a chair of appropriate height?

MANUAL / ELECTRIC RECLINER CHAIR ASSESSMENT FORM : APRIL 2004

Yes Yes

No No

Clinical Justification for Equipment Requested: Transfer in /out of existing chair unduly difficult. Please comment on strategies considered: ♦ Recent PT review – Is chair within program aims? ♦ platform to existing chair / adjust height chair: ♦ high back chair: ♦ cushioning: ♦ other: Assessed need for leg elevation. Please comment on strategies considered? ♦ stockings: ♦ exercise: ♦ bed rest:
Page 2

Surname:

Given Name:

File No.

footstool / legrest: other: Assessed need to change position to manage pain. Please comment on strategies considered? ♦ recent PT review – chair within program aims? ♦ relieving / aggravating factors known: ♦ other management: Need to sit in reclined position: Is this clearly established?

♦ ♦

Equipment Trialed: If modification to existing seating cannot provide functional independence, comment on equipment trialed:

High backed chair: Manual Recliner: MANUAL / ELECTRIC RECLINER CHAIR ASSESSMENT FORM : APRIL 2004

Yes Yes

No No

Electric Recliner: Electric Lift Recliner:

Yes Yes

No No

Recommended chair on completion of assessment:

It is DVA policy to re-issue appropriate equipment unless specifically not recommended by the referring therapist. Reissue Suitable Seating Measurements Seat height: Seat depth: Seat width: Back height: Additional requirements: Please attach quote if supplier equipment trial has been completed
Page 3

Hand controls: cm cm cm cm Right: Manual recliner: Lever: Pushback:: Left: