Formulaire du programme Step-up | Lifemark mieux-être des personnes aînées

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Informations sur l'orientation

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Date de référence

Referral Source

Name of Referral Source

Nom de l'organisation

Numéro de contact

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Fax Number

Courriel

Référence approuvée par le client/SDM

Type of Service

PT-OT

PT-SLP

OT-SLP

PT-OT-SLP

LEGEND: PT = physiotherapy OT= occupational therapy SLP = Speech and Language Pathology

Informations sur le client

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Nom du client

DATE DE NAISSANCE

Genre

Homme

Femme

Preferred not to say

Numéro de contact

Courriel

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Adresse

Ville

Code postal

Langue

Si nécessaire : informations sur le décideur suppléant

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Nom du SDM

SDM Phone Number

Same as client

Numéro alternatif

SDM Email

Same as client

Courriel

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Adresse postale Groupe SDM

Adresse

Identique à l'adresse du client

Autre adresse

Informations médicales

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Médecin de premier recours

Numéro de téléphone

Numéro de fax

Physician Email

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Relevant Medical Diagnosis, History, Interventions / Procedures (please specify)

Clinical Presentations

Nonprogressive

Progressive

Unknown / Not Applicable

Relevant Health Concerns (please check all applicable)

muscle or joint pain

deformity, dislocation, subluxation, sprain or fracture

limitation of motion

muscle weakness or paralysis

muscle stiffness or spasm or spasticity

difficulty balance and coordination

risks of falls/post fall

difficulty in mobility, walking or transfers

requires use of assistive devices (cane, walker, wheelchair, etc. – please specify)

requires use of orthotics/prosthesis (braces, splints, etc.- please specify)

difficulty in fine motor control (hand functions)

difficulty with coordination (shaking)

difficulty in activities of daily living (self-care, bathing, toileting, dressing, eating, cooking, etc.)

memory loss/impairments

emotional/mental health concerns (low mood, stress, lack of motivation, etc.)

difficulty in problem solving in everyday activities or understanding new concepts

difficulty in speaking due to paralysis/weakness (slurred or unclear speech, repetition of words/phrases)

difficulty in formulating, expressing and/or understanding words/sentences

words/sentences sounds jumbled or meaningless

voice changes (low volume, loud, hoarse, rough, etc.)

loss of voice

disruptions in the normal flow of speaking (stutters, interjections, prolongations, etc.)

difficulty in chewing and/or swallowing liquids/solids

acid reflux

requires food modifications or avoids certain foods

hearing loss/impairments

requires the use of communication/hearing devices (please specify)

others (please specify)

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Please specify the reason for requiring orthotics/prosthesis (braces, splints, etc.) below:

Please specify the reason for requiring communication/hearing devices below:

Please specify the reason for requiring assistive devices below:

Considérations pour le programme

Was the client previously enrolled under Lifemark Community Step Up Program?

Yes

Is the client currently undergoing additional therapy services? (if yes, therapy reports may be requested)

Yes

Is the client residing in a Long-Term Care Home?

Yes

Can the client tolerate a minimum of 60-minute session?

Yes

Does the client need assistance in mobility/transfers?

Yes

Does the client need assistance in toileting?

Yes

Does the client show responsive, impulsive or aggressive behaviors?

Yes

Is the client able to understand/speak English?

Yes

Preferred mode of session (depends on availability)

In-person

Online/Virtual

Autres préoccupations

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Formulaire du programme communautaire Step Up

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