Occupational Therapy Boston AMPAC: Follow-Up

1 Caring for Your Quality of Life lifecare of Florida Page 1 of 1 ampac Follow-Up Occupational Therapy Boston ampac : Follow-Up Patient s Last Name First Name MI HICN Provider Name lifecare of Florida Provider No 104545 Onset Date SOC Date Primary Diagnosis(es) Treatment Diagnosis(es) Please check the box that reflects your (the patient s) best answer to each question. Scoring: 1 = Unable 2 = A Lot 3 = A Little 4 = None Date(s) How much difficulty do you currently have: 1. Tying your shoes? 2. Sewing on a button? 3. Pounding a nail in straight with a hammer to hang a picture?

2 4. Unscrewing the lid off a previously unopened jar without using devices? 5. Replacing or tightening small parts using only yours hands ( , screws)? 6. Removing stiff plastic packaging using only your hands? 7. Cutting your toenails? 8. Hanging wash on a line at eye level or above? 9. Washing indoor windows? 10. Moving a sofa to clean under it? 11. Holding a screw and screwing it tight with a manual screwdriver? 12. Lifting 25 pounds from the ground to table height? 13. Lifting 100 pounds or more? 14. Doing 5 push-ups without stopping? 15. Managing clothing behind your back (belt loops, tucking in shirt, bra, Score Therapist s Name & Credentials (Please Print) Therapist s Signature _____ X_____)