Professional Documents
Culture Documents
Assessment
Report
Doctors
DoctorsAccessment
AssessmentForm
Report
Doctors
Assessment
Report
Physical
Paralysis
Weakness or immobility
resulting from stroke
Neurological-related conditions
Muscular degenerative diseases
Amputations or loss of limbs
Intellectual
Down Syndrome
Global Developmental Delay
Autism Spectrum Disorder
Others (please specify):
Sensory Impairment
Visual
Hearing
Multiple Disabilities
Please specify:
Others
Please specify:
Remarks
1. Washing or Bathing
Ability to wash in the bath or
shower (including getting into
and out of the bath or shower)
or wash by other means.
Doctors Assessment
No help is needed
Needs help/ supervision
most of the time
2. Dressing
Ability to put on, take off,
secure and unfasten all
garments (upper and lower)
and any braces, articial limbs
or other surgical appliances.
No help is needed
3. Feeding
No help is needed
4. Toileting
Ability to use the toilet or
manage bowel and bladder
functions through the use of
protective undergarments or
appropriate surgical appliances.
No help is needed
Needs help/ supervision
most of the time
5. Transferring
Ability to move from
(a lying position on the) bed to
an upright chair or wheelchair,
and vice versa.
6. Mobility
Ability to move indoors from
room to room on level surfaces.
No help is needed
Needs help/ supervision
most of the time
No help is needed
Needs help/ supervision
most of the time
Yes/ No
Yes/ No
Yes/ No
Yes/ No
Yes/ No
Name of Doctor
Signature of Doctor
Date
Ofcial Stamp of
Clinic/ Hospital
Telephone No.
Fax No.
** Assessing doctor must sign against any amendment made and affix the official stamp of the clinic.
If not, the report will be deemed to be incomplete.