Screening Tool



Do you have difficulty in any of these areas? An Occupational, Physical or Speech Therapist could help improve function.

Mobility
Takes more than one try to get up from bed, chair, car, tub
Difficulty propelling and guiding wheelchair
Leans to one side while sitting or walking
Difficulty managing in kitchen with walker
Activities limited by breathlessness, dizziness or fatigue
Has periodic loss of balance, clumsiness or tripping

Home Safety
Needs grab bars, ramps, and accessibility or equipment ideas
Does not have plans for emergency situations
Difficulty using the phone or calling for help
Difficulty maneuvering through some places in home
Inability to recognize unsafe situations

Personal Care (Dressing, Hygiene & Toileting)
Difficulty using toilet, tub or shower safely
Difficulty reaching parts of body (shampoo, dress, toilet)
Poor oral hygiene
Diffculty managing undergarments, clothing and fasteners
Difficulty managing toileting task
Difficulty donning shoes and socks
Stays in pajamas instead of getting dressed

Upper Extremity Functions
Decreased sensation in hands, tendency to drop things
Difficulty reaching high cupboards, hanging clothes
Difficulty signing name
Difficulty tying shoes, buttoning, opening containers

Eating
Difficulty getting food to mouth (loading utensil, reach, aim)
Pocketing food in cheek
Coughing after eating or drinking

Perceptual Motor Skills
Cannot complete an activity successfully
Cannot demonstrate what was just said
Inability to find things in drawers
Bumping into furniture or doorways, missing first or last step

Cognitive Skills
Inability to follow medication's dosage schedule
Difficulty making change, ordering from menu, using phone
Poor orientation or problem solving
Behaviors make caregiving difficult (wander, scream, pick, hit, resist care)

Coping Skills
Lack of interest in people and plans
Resistance to change
Despair regarding loss of function
Negative responses to dependence

If you checked any of these problems, an Occupational, Physical or Speech Therapist may be able to help. Contact Therapy In Your Home for more information.


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Screening tool by Karen Johnson, OTR, and Julie Groves, OTR.