Background Information and Occupational Intake – Adult

Background Information

client full name(Required)
Is your primary language spoken English?
If English is not your primary language, an interpreter may be provided by your insurance. Would you like an interpreter for your services?
If yes, please provide language needed(Required)
No, I would like to opt out of interpreter services
Client's Name(Required)
MM slash DD slash YYYY
Age(Required)
Address(Required)

    Background Information



    YesNo


    YesNo


    YesNo


    Referring Information


    Medical History


    PsychologistPTSpeech and LanguageNutritionistBehavioral SpecialistOther:

    * - Please note frequency/duration of services (e.g. PT 1x/week for 60 minutes)


    Self-Care Skills

    Please check the box that most accurately reflects the amount of assistance needed for the client to complete the following:


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Independent (no cues, prompts, or assist)Supervision (verbal, visual cues; no physical assist)Minimal assistance (1-25%)Moderate assistance (26-50%)Maximum assistance (51-75%)Total assistance (76%-100%)


    Range of Motion (ROM) / Pain Levels

    For the “Pain Level” columns, please write a number between 0-10 (0 = no pain, 10 = max pain).

    For the range/motion columns, please check one of the three boxes that most accurately reflects your current range of motion in the following areas:

    Body Part & Movement

    Pain Level – at rest

    (0-10)

    0 = no pain

    10 = max pain

    Pain Level – at max range

    (0-10)

    0 = no pain

    10 = max pain

    Range/Motion

    Neck - looking left and right

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Neck - looking up and down

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Neck - tilting head to touch shoulder

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Shoulder – lifting arm straight in front, up towards ceiling

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Shoulder – lifting arm to the side (like a butterfly), up towards ceiling

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Elbow – bending

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Forearm – turning to palm up

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Forearm – turning to palm down

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Wrist – moving left and right

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Wrist – moving up and down

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Thumb – touching pinky

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Thumb – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Pointer finger – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Middle finger – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Ring finger – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion

    Pinky finger – bending finger joints

    Typical Range/MotionLimited Range/MotionNo Range/Motion


    Sensory Processing Checklist

    The purpose of this sensory processing checklist is to help you become educated/aware about particular signs of sensory processing dysfunction and allows the professional to gather a background of behavior responses. It is not to be used as a diagnostic criteria for labeling any sensory processing disorder; but rather, as an educational tool and checklist for knowledge. Please check symptoms that you feel best describe your current sensory behaviors/patterns.

    Tactile Sense: input from the skin receptors about touch, pressure, temperature, pain, and movement of the hairs on the skin.

    Proprioceptive Sense: input from the muscles and joints about body position, weight, pressure, stretch, movement, and changes in position in space.

    Vestibular Sense: The vestibular system is the sensory system that responds to motion or change of head position. The receptors for movement are located in the inner ear. They tell the brain what direction the head is moving, the speed of the movement and where we are in space.

    Other Senses: There are also sensory processing skills related to the visual (sight), auditory (sounds), oral (mouth, taste), olfactory (smell), and interoceptive (inner control, such as bladder & bowel, self-regulation).

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