First Assistive Technology Session
History:
Referred by whom and for what reason:
Diagnosis/background:
Preferred way to be addressed:
Current Location:
Branch of Service:
Current Phone Number:
Current Email:
Other Reported Rehab Services:
Learning Style:
Barriers to Learning:
Subjective:
Client’s stated goal(s):
Current pain level and description:
Client report of current technology and strategies/
Client report of strengths or limitations with current strategies:
Observation:
Total Time Spent with Client:
AT Assessment (evaluation) 97755:
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2.
3.
4.
5.
Client’s cognitive strengths/limitations:
Client’s physical strengths/limitations:
Client’s emotional strengths/limitations:
Environment(s) appropriate for use of adaptive technologies:
Patient education:
Assistive Technology:
Patient Demonstration of Current Strategy:
Items Demonstrated and/or Described:
Equipment Provided:
Assessment (summary and impressions):
Client has limitations with _____due to _____________________
Introduction of adaptive hardware/software will likely improve this client’s ability to perform his
daily activities and his satisfaction with his daily activities.
Plan for next session:
Date and time of next scheduled appointment: