Académique Documents
Professionnel Documents
Culture Documents
Halifax
6452 Quinpool Road
Halifax, Nova Scotia B3L 1A8
Tel: 902.404.3239 Fax: 902.755.2813
PERSONAL DATA
Name: _______________________________
Address: _____________________________
_____________________________
_____________________________
Single
Married
Common law
Separated
Divorced
Widowed
Number of years:
Number of years:
Number of years:
Number of years:
Number of years:
Number of years:
__________
__________
__________
__________
__________
__________
Ages: _______________
Ages: _______________
INJURY INFORMATION
Date of Accident: __________________________________________________
What were your injuries at the time of the accident?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Has your sleep been affected since the accident? Please describe:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Has your overall mood been affected since the accident? Please describe:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
VOCATIONAL INFORMATION
Education Level Completed: _________________________________________
Name of School: ___________________________________________________
What year did you finish your schooling? ______________________________
Your Occupation:
At the time of the accident: ____________________________________
At the present time: __________________________________________
Your Employer:
At the time of the accident: ____________________________________
At the present time: __________________________________________
How long did you work for your most recent employer? _________________
Please provide a brief description of your job responsibilities:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Has an Occupational Therapist visited your home or worksite since your
injury? YES _____ NO ______
Have you returned to work since the accident? (Please check as many as
apply)
How long are you able to stand before having to get up and move around
because of pain?
__________________________________________________________________
__________________________________________________________________
How long are you able to walk without the need to rest?
__________________________________________________________________
__________________________________________________________________
Please indicate the degree of difficulty you may have with the following
actions/activities on a scale from 1 to 10 (0= no difficulty; 10= severe difficultly)
Activity
0= no difficulty
10= severe difficultly
Bending Forward
0
1
2
3
4
5
6
7
8
9
10
Kneeling
0
1
2
3
4
5
6
7
8
9
10
Pushing
0
1
2
3
4
5
6
7
8
9
10
Pulling
0
1
2
3
4
5
6
7
8
9
10
Carrying
0
1
2
3
4
5
6
7
8
9
10
Squatting/Crouching 0
1
2
3
4
5
6
7
8
9
10
Balancing
0
1
2
3
4
5
6
7
8
9
10
Lifting
0
1
2
3
4
5
6
7
8
9
10
Reaching Overhead 0
1
2
3
4
5
6
7
8
9
10
Climbing stairs
0
1
2
3
4
5
6
7
8
9
10
Please provide details on how the above actions affect you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Please think about the following activities of your daily living. Then, put a
check mark under the category that best describes your present situation:
SELF CARE
Activity
Self Care
I am
completely
unable to
do this
activity
since my
injury
Unable to
do this
activity
Daily
Grooming
Washing Hair
Bathing
Shower
Dressing
Shaving
From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
HOUSEHOLD ACTIVITIES
Activity
Household
Activities
Check
here if
you did
not do
this
activity
before
your
injury
Mild (I
have little
or no
difficulty)
Moderate
(I have
some
difficulty
most of
the time,
and it
takes me
longer to
do this
now)
Severe (I
Unable to
have
do this
considerable activity
difficulty all
of the time,
and need
help from
others)
Sweeping
Vacuuming
Mopping
Laundry
Washing/Drying
dishes
Making beds
Changing bed
sheets
Preparing meals
Cleaning the
Oven
Grocery
Shopping
Fall/Spring
Cleaning
Cleaning
Windows
Interior House
Painting
Cleaning
Tub/Toilet
Dusting
Taking out
Garbage
Ironing
Wood Stacking
or Splitting
(Wood Stove)
From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
External Home
Maintenance
(Outside the
house)
Check
here if
you did
not do
this
activity
before
your
injury
Mild (I
have little
or no
difficulty)
Moderate
(I have
some
difficulty
most of
the time,
and it
takes me
longer to
do this
now)
I am
completely
unable to
do this
activity
since my
injury
Severe (I
Unable to
have
do this
considerable activity
difficulty all
of the time,
and need
help from
others)
Gardening
House
Repairs/Maintena
nce
Snow Shoveling
Exterior House
Painting
Lawn Mowing
Raking Leaves
Spring/Fall Clean
up
Chimney
Cleaning
Car repairs/
Maintenance
Car cleaning
Driving a car
From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
10
SOCIAL/RECREATIONAL
Activity
Social/
Recreational
Check
here if
you did
not do
this
activity
before
your
injury
Mild (I
have little
or no
difficulty)
Moderate
(I have
some
difficulty
most of
the time,
and it
takes me
longer to
do this
now)
I am
completely
unable to
do this
activity
since my
injury
Severe (I
Unable to
have
do this
considerable activity
difficulty all
of the time,
and need
help from
others)
Socializing with
friends
Visiting with
Family
Taking part in
sports
Watching sports
Engaging in
hobbies
Reading
Going to movies
Using a computer
From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
11
From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Child care
Activity
Child care
Check
here if
you did
not do
this
activity
before
your
injury
I am
completely
unable to do
this activity
since my
injury
Mild (I
have little
or no
difficulty)
Unable to
do this
activity
Moderate
(I have
some
difficulty
most of
the time,
and it
takes me
longer to
do this
now)
Severe (I
have
considerabl
e difficulty
all of the
time, and
need help
from
others)
Supervision
and play
Driving to
activities
Caring for an
ill child
Diapering and
toileting
12
From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Pet Care
Activity
Pet Care
Check
here if
you did
not do
this
activity
before
your
injury
I am
completely
unable to
do this
activity
since my
injury
Mild (I
have little
or no
difficulty)
Unable to
do this
activity
Moderate
(I have
some
difficulty
most of the
time, and
it takes me
longer to
do this
now)
Severe (I
have
considerable
difficulty all
of the time,
and need
help from
others)
Grooming
Bathing
Walking
13
From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
MEDICATIONS
Please list the medications that you are presently taking as a result of your
injury. (Do not list medications that are not related to your injury). Please
list the prescription and non-prescription medication(s), the dosages, and how
many times a day you take each medication.
Prescription medications I am presently taking
Full Name of Medication Dosage (typically in mg.)
14
GENERAL INFORMATION
Financial:
What is your present source of income? (Check all that apply)
Description of Home:
Do you own or rent your present home? Own _____ Rent _____
How long have you lived at this location?
__________________________________________________________________
Number of bedrooms in your home _____ Number of bathrooms in your
home _____
How many levels does you home have? ________________________________
What size lot is your house on? _______________________________________
On what level are your laundry facilities? ______________________________
Do you have a finished basement? ____________________________________
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Finally, please comment on the impact the injury has had on your life and the
life of your family:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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