Occupational Therapy Home Assessment form.

Client’s Health and Medical Condition.O is a 14 year old girl with a diagnosis of quadriplegic spastic cerebral palsy (GMFCS
Level 5 and MAC level 5).
Current medications:- epilim, gabapentin, lamotrigine, kepra, zoton, glycopyrrolate,
baclafin, artan, bactrim and medazlon.
Days of work:-
Registration Number:-
Medicare Provider Number
Social Situation.Client Name:
Date 10 May 2016
O resides with her two older sisters, and her mother (K) and father (G). Her
grandparents reside in an adjoining property. Residence built in 2004-5 with design
taking into consideration O needs at that time.
Client’s Functional Status.O mobilises with an attendant care manual wheelchair. She is dependent on her carers
for all activities of living(ADL) and instrumental activities of living (IADL).In receipt of
morning and afternoon personal care, and in home respite.
O is fed via a gastrostomy, and she requires suctioning to manage her secretions during
the day. K reported that O silently aspirates during the night and requires additionally
suctioning during this time.
Equipment Used.Item Comment
Manual wheelchair Mother advised that electric wheelchair
will be scripted in the future.
Hi Lo hospital bed with pressure encased
Clear path of travel and circulation space
will require consideration in home
modification design.
O is tall for her age, and current bed is not
suitable for her anthropometrics, and her
orthopaedic requirements (O has rods in
her back).
O will require a king single hi lo bed to
Days of work:-
Registration Number:-
Medicare Provider Number
accommodate her height.
Client Name:
Date 10 May 2016
Wall mounted fold down shower tray wall
in hobfree step down shower recess
Showertray is still appropriate for use.
Ceiling tracking hoist in bedroom 2. Current tracking hoist does not work.
Limited circulation space surrounding bed
and potential for manual handling risks for
Continence pads
Sonata heavy duty electric hoist and sling The hoist allows for movement from bed to
chair and bathroom, however it is limited
in existing the bedroom door and turning
90ᶿ to access hallway to bathroom and
then 90ᶿ to enter bathroom area.
Home Environment.Single storey brick residence on concrete slab.
Access:- Front The home is accessed from the road via a gravel drive, joining to a
paved pathway. There is a garage on the left on facing. . This is not the preferred
entrance. Height of step into house 160mm, limited space due to front pillars at
Days of work:-
Registration Number:-
Medicare Provider Number
Client Name:
Date 10 May 2016
Whilst this access can be modified it is not the preferred access due to
 Front door would require widening to accommodate a wheelchair
 Path of travel is narrow and would require carer to undertake 90ᶿ turn. This
presents a manual handling risk to navigate to main family living area and
 O would be exposed to the elements of an uncovered ramp which are
detrimental to her health, and the side ramped entrance is under cover.
Side access:-
This is the preferred access. Currently accessed via drive through garage. The rear
yard is covered, which prevents Olivia being exposed to the elements when
The existing brushed concrete ramp does not comply to the National Construction
Code (NCC) and Building Codes (BCA)(2016) being 270mm in height and 2220mm in
length, thus providing approximately 1:8 gradient on a ramp that should be 1:14
(NCC/BCA 2016 and in consideration of AS 1428.1 (Design for Access and Mobility.
Part 1(2009, Incorporating Amendment No 1): General requirements for access- New
Building work) .
Days of work:-
Registration Number:-
Medicare Provider Number…………………………………….

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