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PHYSIOTHERAPY DEPARTMENT
PREFERRED NAME:
NAME: .....
CONSULTANT: .
DOB: UNIT NO: .
GP: ...
NHS NUMBER: ..
ADDRESS: .
ADDRESS: ..
...
AMPUTATION DETAILS:
Respiratory conditions
Other
DOB: ..
UNIT NO: ..
DRUGS HISTORY: Has medication review taken place in last 6 months: Yes / No
*Falls risk: Poly pharmacy 4 or medicines
CONTINENCE
Bowels:
SENSORY
Car driver: Driving after Amputation, 6th edition Oct 2006 Booklet given
RDAC Empowering people Leaflet given
Occupation:
SOCIAL HISTORY
House Own
Part of a House Rented
Bungalow Council
Flat With Spouse
Sheltered With family
Other Alone
ACCESS (indicate number of steps/ramp/rails etc): *Falls risk:: has environment been assessed
Front Rear/Side
Outdoor steps/slope
DOB: ..
UNIT NO: ..
AMENITIES
Bathroom / Shower Toilet
Other
Shopping Cooking
Aids used:
Wheelchair Motorised Scooter
Indoors:
Aids used:
Wheelchair: self propelled Electric: indoor outdoor
Wheelchair mobility
Bed mobility
Dressing
Transfers
DOB: ..
UNIT NO: ..
PHYSICAL ASSESSMENT
RESIDUUM:
Wound Pain
Oedema
Phantom sensations
*Falls risk
ROM/POWER
HIP
KNEE
ANKLE
SKIN CONDITION *1
SENSATION / PROPRIOCEPTION
PRESSURE AREAS
*1 SKIN include: temp, colour, hair growth, nail condition, oedema, presence of lesions
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
DOB: ..
UNIT NO: ..
ROM/POWER
ARMS: Left Right
SHOULDER
ELBOW
WRIST
HAND / GRIP
SKIN CONDITION *1
SENSATION / PROPRIOCEPTION
*1 SKIN include: temp, colour, hair growth, nail condition, oedema, presence of lesions
PULSES
RIGHT LEFT
Femoral Femoral
Popliteal Popliteal
Posterior Tibial Posterior Tibial
Dorsalis Pedis Dorsalis Pedis
DOB: ..
UNIT NO: ..
Wheelchair mobility
Bed mobility:
Rolling Sitting up Bridging
Step Stairs
DOB: ..
UNIT NO: ..
ARTIFICIAL LIMB
Type: Prosthetist:
Progress towards achievement of patients own long term expectations / goals (see separate
document)
Toilet Bath
Step Stairs
Other
DOB: ..
UNIT NO: ..
DATE:
4. Walk indoors
TOTAL SCORE:
DESIGNATION OF ASSESSOR:
KEY:
1 = No 2 = Yes, if someone helps 3 = Yes, if someone is near 4 = Yes, alone
DATE:
DESIGNATION OF ASSESSOR