Page 37 - วารสารกรมการแพทย์แผนไทยฯ ปีที่ 3 ฉบับที่ 3

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5
Functional Evaluation

OT PT PO
Functional Helped Perception ADL Bed Activity Ambulation Grip Foot
Status (%) Body Visual Apraxia Bed Eating Dress Lying to Sitting to With Without drop
Image Mobility Sitting Standing Gait aid Gait aid
1. Total 100 Part Contact Promote No -OM No Canût sit Canût std Useless Gr0
dependence Follow motor Action Funct Move Hand
2. Partial >50 Relation Fig.grd Auto Pusg Sh AbnOral Sit w H&N Lump & Swing Flex Grl-2
dependence Form & hip reflex Spurt support Leg Sp Leg Sp Wrist
3. Partial <50 R&L E&H Model Super 1-hand Super Hip Knee Balance Extend Gr3-4
independence coominat Vision Technq vision support Support Support Wrist
4. Total 0 space Position Function Self Self Self Self Self Self Self >4 kg GR5
independence Spatial BM eat Dress sitting standing Standing Walk
Pre-morbid Function lEntered Program Discharged Program
Onset date..................... (Date .....................) (Date......................)
(Post onset .................days) (Post onset .................days)
Program duration..................days
Treatment program/Intervention:
Medical :
Surgical(Craniotomy,Craniectomy,AVM clipping,romoved clot) 6
Rehabilitation & Acupuncture program

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OT PT PO Acupuncture
Perception ADL Bed Activity Ambulation
Patient Class B1 V Apx Bed Eat Dress Lying to Sitting to With W/O
Mobility Sitting Standing Gait Gait
Aid Aid
1.Sleep-sit B11 V1 Apx1 Bm1 E1 D1 LS1 WHO Acp1
2.Sit-stand B12 V2 Apx2 Bm2 E2 D2 LS2 SS1 WHO Acp2
3.Stand-Walk B13 V3 Apx3 Bm3 E3 D3 LS3 SS2 GA1 WHO Acp3
With Assist
4.walk B14 V4 Apx4- Bm4 E4 D4 LS4 SS3 GA2 Wol WHO Acp4
(no assist)
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Date 1 2 3 4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
Day
OT
PT
PO
≈ß™◊ËÕ OT............................. PT........................................PO.............................................
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