DFS - Clients - OT Background Information Form

Therapist Name *

Therapist Email *

Today's Date *

Background Information

Client Details

Client Name *

Date of Birth *

Current Age *

Address *

Contact Number *

Email *

Diagnosis / Conditions *

School(If applicable)

Employment / Programs(If applicable)

Highest level of education *

Date of Evaluation *

Referred By: *

Date *

Health Details

Pregnancy and Birth

Complications *

Type of Delivery *

Difficulty Breathing / Drinking *

Noted Development as a Child

Talking *

Crawling *

Walking *

Interaction *

Other

General Health *

Assistive Devices *(Examples include wheelchairs, glasses, hearing aids, weighted blankets, etc.)

Medication *

Previous Therapy *

Current Concerns

Personal Information

Relationship Status *

Dependents *

Financial Support *

Family Structure and History

Parents *

Siblings *

Living Arrangements *

Accommodation

Owner of Housing *

People Living in the House *

Type of House *

Kitchen *

Rooms *

Bathroom Facilities *

BathShowerIndoor Toilet FacilitiesOutdoor Toilet Facilities

Water *

InsideOutside

Electricity *

InsideOutside

Security *

FenceBurglar AlarmsAlarm System

Garage *

Manual DoorsAutomatic Doors

Garden *(Including size)

Stairs *

Facilities in the Area and Distances from the Place of Residence

Shop

Estimated Distance *

Type of Transport *

Costs Involved *

Taxi Stop / Bus

Estimated Distance *

Type of Transport *

Costs Involved *

Local Clinic

Estimated Distance *

Type of Transport *

Costs Involved *

Closest Hospital

Estimated Distance *

Type of Transport *

Costs Involved *

Work

Estimated Distance *

Type of Transport *

Costs Involved *

Functional Capabilities

Please indicate:

What the client is able to do independently
What they need assistance with
Type of assistance (e.g. quality check, physical assistance, prompting to do or complete task)

Sleep

Falling / Staying asleep *

Typical nighttime routine *

Dressing

Choosing clothing *

Putting on Tops / Jacket *

Putting on Trousers / Dress *

Putting on Shoes / Socks *

Putting on Underwear *

Hygiene

Bath / Shower *

Washing *

Drying Body *

Grooming

Drying / Brushing / Cutting Hair *

Cutting Nails *

Shaving *

Makeup *

Toilet Hygiene

Knows When to go to the Toilet *

Wiping *

Hand Hygiene *

Sexual Intercourse
(If applicable)

Household Management Skills

Domestic Assistance

Difficulties With *(Laundry, Cleaning Room, Cleaning Home, Packing School Bag, etc.)

Who Performs Tasks? *

Assistance Hired(If applicable)

Garden Assistance

Difficulties With *

Who Performs Tasks? *

Assistance Hired(If applicable)

Maintenance Work

Difficulties With *

Who Performs Tasks? *

Assistance Hired(If applicable)

Care

Difficulties With *

Assistance Hired(If applicable)

Community Mobility and Transport

Driver’s Licence *

Type of Transport Utilised *

Problems experienced while travelling

Physical *

Psychological *

Shopping *

Life Skills *

Leisure: Sport and Recreation

Type of Activity *

Frequency *

Qualifications and Occupational Background

Educational Background *

Tertiary Education / Other Training *

Work History

Estimated Time of Service *

Employer *

Occupation *

Reason for Leaving *

Work Employment Description at Time of Accident

Job Title *

Employer *

Working Hours *

Salary *

Team Setup *

Travel Requirements *

Environment *

Job Demands

Physical Demands (frequency)

Sit / Drive *

Stand *

Walk *

Squat / crouch / bend / knee / stoop *

Climbing *

Reaching *

Pushing / pulling *

Levels *

Weight handling (kg and frequency) *

Cognitive Demands

Tools and Equipment

Problems

Problems at School or Work

Future Plans

Typical Day

Time *

Task *

Epilepsy

Pain

Where on Body? *

Type *

StabbingBurning

Cause and Intensity *

Where on Body?

Type

StabbingBurning

Cause and Intensity

Where on Body?

Type

StabbingBurning

Cause and Intensity

Where on Body?

Type

StabbingBurning

Cause and Intensity

Medical Data

Body Weight *

Height *