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Doctors

Assessment
Report

Doctors
DoctorsAccessment
AssessmentForm
Report

Doctors
Assessment
Report

2 Doctors Assessment Report

Name of Person Assessed

Section 1: Type of Disability


Disability Type

Please Tick All that Apply

Physical
Paralysis
Weakness or immobility
resulting from stroke
Neurological-related conditions
Muscular degenerative diseases
Amputations or loss of limbs

Intellectual
Down Syndrome
Global Developmental Delay
Autism Spectrum Disorder
Others (please specify):

Sensory Impairment
Visual
Hearing

Multiple Disabilities
Please specify:

Others
Please specify:

Date of onset of disability (please indicate):

Remarks

Doctors Assessment Report 3

Name of Person Assessed

Section 2: Functional Assessment


Activities of Daily Living

1. Washing or Bathing
Ability to wash in the bath or
shower (including getting into
and out of the bath or shower)
or wash by other means.

Doctors Assessment
No help is needed
Needs help/ supervision
most of the time

2. Dressing
Ability to put on, take off,
secure and unfasten all
garments (upper and lower)
and any braces, articial limbs
or other surgical appliances.

No help is needed

3. Feeding

No help is needed

Ability to feed oneself after


food has been prepared and
made available.

Needs help/ supervision


most of the time

Needs help/ supervision


most of the time

4. Toileting
Ability to use the toilet or
manage bowel and bladder
functions through the use of
protective undergarments or
appropriate surgical appliances.

No help is needed
Needs help/ supervision
most of the time

5. Transferring
Ability to move from
(a lying position on the) bed to
an upright chair or wheelchair,
and vice versa.

6. Mobility
Ability to move indoors from
room to room on level surfaces.

No help is needed
Needs help/ supervision
most of the time

No help is needed
Needs help/ supervision
most of the time

Doctors Remarks/ Comments

4 Doctors Assessment Report

Name of Person Assessed

Section 3: Comments by Doctor

Please Delete Accordingly

Yes/ No

Is the person with disability dependent on a full-time caregiver


in at least 1 of the above ADL needs?

Yes/ No

Is the disability permanent?

Is the functional status likely to change within 3 years?

Yes/ No

Does the person with disability have at least moderate disability?

Yes/ No

Is the person with disability able to travel by himself/ herself to


the nearest polyclinic for primary care?

Yes/ No

Additional comments (if any)

Name of Doctor

Signature of Doctor

Date

Ofcial Stamp of
Clinic/ Hospital

Telephone No.

Fax No.

** Assessing doctor must sign against any amendment made and affix the official stamp of the clinic.
If not, the report will be deemed to be incomplete.