Reason for Services
Occupational History & Success
Contexts: Environment & Personal
Performance Skills & Patterns
Client Goals & Priorities
100

What is Alice’s primary diagnosis?

Multiple Sclerosis (MS)

100

What was Alice’s profession before she retired?

 Middle school teacher

100

Where does Alice live?

In a two-story home in a rural area

100

What physical skills are most impacted by Alice’s MS?

Balance, lower extremity strength, and coordination


100

What is a primary safety goal for Alice?

Reduce fall risk with improved balance strategies

200

How long has Alice been living with MS?

18 years

200

Why did Alice retire?

The job became too physically demanding due to her MS symptoms

200

What environmental challenge could increase Alice’s fall risk?

Stairs to the second floor where her bedroom is located

200

What recent functional change has Alice experienced?

Increased falls and difficulty with household tasks

200

What home management task does Alice value most?

Maintaining her independence in meal preparation

300

What recent issue prompted her referral to home health OT?

Increased falls and concerns about her safety at home

300

What hobbies did Alice enjoy before MS impacted her function?

Gardening and reading magazines.

300

Who are Alice’s social supports?

Two grown children who live out of state and her ex-husband Jim, who helps with home maintenance.

300

Why is Alice at risk for poor safety awareness?

Her confidence may cause her to overestimate her abilities

300

What community activity does Alice want to continue?

Reading magazines and staying informed.

400

What secondary condition does Alice also have?

Hypertension

400

Why is it important to acknowledge Alice’s teaching background in therapy?

It highlights her strong personality, independence, and desire for control.

400

How does Alice’s personality impact her therapy participation?

She is confident and may resist suggestions she sees as unnecessary.

400

How does fatigue impact Alice’s daily routine?

She may become easily exhausted, reducing her ability to complete tasks

400

How can energy conservation techniques help Alice?

They help her manage fatigue and maintain participation in activities

500

Why does Alice feel resistant to home health therapy?

She feels her doctor is “overreacting” and is confident she is managing fine.

500

How can Alice’s past success in education be used therapeutically?

Teaching her compensatory strategies can leverage her problem-solving skills

500

Why is it important to involve Alice in therapy planning?

She is more likely to engage if she feels she has control and choice

500

What visual skill could also be impacted by MS?

Visual tracking and focus, affecting reading and mobility

500

Why is emotional resilience an important focus for Alice?

Her confidence may be a protective factor, but it can also be a barrier to adapting to change