Selects appropriate clothing for season / activity Knows when clothing needs to be changed Grasps / holds clothing articles Knows when clothes are right side out vs. inside out Recognizes modesty issues during dressing Puts on bra Puts on Puts on shoes on correct feet Uses Velcro closures Ties laces Wears appropriate footwear in the daytime Wears appropriate footwear at night Removes socks Removes Removes shirt Removes bra Removes underwear Fastens buttons Zips zipper Applies / removes belt Resident Preferences Selects own clothing Uses adaptive / assistive device(s). If yes, specify: Expresses preferences: COMMENTS (EXAMPLES: 1) Resident would benefit from learning how to put shoes on correct feet; 2) Resident should not wear clothing with buttons or snaps; and 3) It is important that the resident wears baseball hats): Hygiene / Grooming Skills: On each line below, enter the number that best represents the resident’s present level of ability for each skill: 1. Physical 3. Verbal 5. Self-Reliant 2. Gestural 4. Independent N/A Not Applicable Knows when to brush teeth Opens toothpaste tube Puts toothpaste on toothbrush Y N Tolerates toothbrush Makes brushing motions Brushes teeth / gums Uses dental floss Rinses mouth Turns on water Rinses toothbrush and puts away Applies soap to hands Makes rubbing motion with hands Washes face Rinses hands Dries hands Gathers / puts away grooming items Brushes / combs hair Styles hair Y N Tolerates beautician / barber cutting hair Requests hair appointment Applies deodorant Aware of when to be shaved Shaves self with electric razor Mouth wash (fluoride rinse) Applies aftershave / cologne / perfume Provides own fingernail care Uses nail clippers Blows nose with tissue Understands need for good hygiene / grooming Uses mirror during care Applies make-up Cleans dentures Cleans glasses Cares for hearing aid Provides own Menses care Resident Preferences Expresses preferences: COMMENTS (EXAMPLES: 1) Resident has expressed fear that soap will burn eyes; AND 2) Resident just received glasses. Could learn to store properly): Toileting Skills:
Discriminates between hot / cold food Pours liquid from pitcher Understands “healthy food” vs “junk food” Equipment Needed: See OT Assessment, DSHS 10-XXX, for all adaptive equipment. Meal Preparation: Y N Resident assists with meal preparation; if yes, specify: Resident Preferences: Y N Expresses preferences: Participates in making choices: COMMENTS (EXAMPLES: 1) Resident is only provided spoon. Could use training in the use of a fork; 2) Has tendency to throw items; AND 3) Resident could benefit from learning to pour his / her own liquids): Household Management Skills: On each line below, enter the number that best represents the resident’s present level of ability for each skill: 1. Physical 3. Verbal 5. Self-Reliant 2. Gestural 4. Independent N/A Not Applicable Knows when cleaning / organizing of personal space should be done Keeps own area tidy Makes bed Stores and maintains own property Dust / surfaces Empties trash Turns on / off lights Turns power on / off (TV, radio, etc.) Puts dirty laundry / clothes in hamper Brings dirty laundry to laundry room Sorts clothing Loads / unloads washer and dryer Folds clothing clothing Puts away own clothing table Prepares a sandwich or food item Puts centerpiece on Puts placemats on Puts napkins on Puts glasses on table Puts silverware on table Puts plates / bowls on table Selects clothing protector / napkin Places clothing protector / napkin in hamper Busses dishes from table Locks / unlocks lock with key Y N Understands responsibility of key possession (i.e., does not give key to others, keeps key safe, uses it for intended use. Tells time: by event by timepiece Resident Preferences: Expresses preferences: COMMENTS / OPPORTUNITIES FOR INCREASING INDEPENDENCE AND RIGHTS (EXAMPLES: 1) Activates electronics with use of a switch; AND 2) Resident can fold clothes but could work on putting them away in his / her drawers): Money Management Skills: On each line below, enter the number that best represents the resident’s present level of ability for each skill: 1. Physical 3. Verbal 5. Self-Reliant 2. Gestural 4. Independent N/A Not Applicable