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How do you determine a disability? What are various types of disability? Eye Disability
Patient Name: _______ Date: _______ Source: Patient _______ Other_______ HISTORY ITEMS Have you had any falls in the last year? Abnormal Yes ACTION Gait assessment Further exam, home evaluation and Physical therapy. Osteoporosis and injury risk assessment RESULT AND COMMENTS Do you have trouble with stairs, lighting, bathroom hazards, or other home hazards? Abnormal Yes to any ACTION Home evaluation or Physical Therapy RESULT AND COMMENTS Do you have a problem with urine leaks or accidents? ACTION RESULT AND COMMENTS Over the past month, have you often been bothered by feeling sad, depressed, or hopeless? ACTION RESULT AND COMMENTS During the past month, have you often been bothered by little interest or pleasure in doing things? ACTION RESULT AND COMMENTS Do you ever feel unsafe where you live? Abnormal Yes ACTION Explore further, social work, APS RESULT AND COMMENTS Does anyone threaten you or hurt you? Abnormal Yes ACTION Explore further, social work, APS RESULT AND COMMENTS _______________________ Is pain a problem for you? ACTION Evaluate _______ RESULT AND COMMENTS _______________________ Do you have any problems with any of the following areas? Who assists? Do you use any device? (for "yes" answers, consider causes, social services, and home eval/Physical Therapy/Occupational Therapy) Doing strenous activities like fast walking/bicycling? __________________________________________ Cooking? __________________________________________ Shooping? __________________________________________ Doing heavy housework like washing windows? __________________________________________ Doing laundry? __________________________________________ Getting to a place beyond walking distance by driving or taking a bus? __________________________________________ Managing finances? __________________________________________ Getting out of bed/transfer? __________________________________________ Dressing? __________________________________________ Toilet? __________________________________________ Eating? __________________________________________ Walking? __________________________________________ Bathing (sponge bath, tub or shower)? __________________________________________ Review medications that the patient brought in Also ask about herbs, vitamins, supplements, and nonprescription medications PHYSICAL EXAM ITEMS (The next few items may be performed by nursing staff in some settings) |