Rebab Checklist
2
a 4 t ) .:. 1| ? : t t : 2 ' - : ' '-j :: a ,$ll Part f. in rr'.r,"*"' incal,,"' z, pu l m "X" besidc thc m.in rhingspr c vcnllngor discoura8ing yo ( lromrcrurn, inglo your regular lifestylc(indicald nl l lhc reasons th.l applyt) yo!). Th.n, complet € Part 2 as instrucredbrlo$. l. ) Physical r € strictions in (check): 2.) llcadaches l.) Problenswithdiziness 4.) Pain s . ) 7. ) s . ) 9 . ) 10.) I l.) l l . ) r3.) Dbcnding dlifling Oseeitrgmd/or Oreaching l:.) I)cp.ession 21.) |lnbnrrlsscd rboutdisabilily dr socinl discriminatio l : 1 . )l - a c ko l c d u c a t i o r or slills i5.) Fc\\'j0bsavailablc in honearcr 16 . ) Mcnrtllf or leamingproble|ni 1 7. ) Luckof enerSy. fceling iltigucd 1 8 . ) (onrlbrl withpresent lilcstylc 19.)Lcg.tlproblens 20.)An\ietyor strcss 2 1 . ) Unable lo cngnSe i n sponsorhobbies 2,1.) I)angcr 0l prc\ious\\'orl 25.) Problcnrs wirh(check): 26.) CoDcc|llrfllir problcms 27.) Not suilcd $ previouswork 28.)Dil]lculty lcarmDg ona newJob 29.)ScxLll|ldificully 30.)DiftlcultycngngiDg in social nctivirics 31.)Dcpcndence o r problenrs w n h (chcck): SpeciS IocaLion\ i n nrioriL)l Dillicultyobtainingajobdu eto my disubility Problcnrs with nry cmployer Fcrr of r € irjury orworseningcondition I)iilicullyslccping Emolional problems l,rohlcnrs with (chcck); Dislikeofprc!iousr.orkor workplace I)ifiicnlty lindingNell-paying jobs Jo bsrcsso. adjusttug to chrnginSjobdcnuMs Spcciry: Omarriagci hnrily or Olackoi support Specifyl OdrivinSlnd/or Olakingpublic rransportation Omedicntionan&)r Clsideefects ' lr(xJrng UqfllIrt rn(lur LrrarhrnellL OspeakiDs Ohearingaod/orOv'sron Onishhnres and/orOfl ashbacts ll.) 13.) l.l.) 16.) 17.)Il|nployerdiscriminafior) 38.)I'roblcnrs !\i!h(check): 39.) Problcnrs with (check)l 4 0 . )P o o rI n g l i s l rs k i l l s ., 1 I.) Acciden!-rclalcd (check): ll.) feir ol driving. \'ork cnlironment. 43.) Initrbili ty/ang.r .ont.ol 4.1.)Finrnci!l dilliculric\ (check): 45.)Scizurcs Difficuhyndjusring to a new io b Worried about layoff fearol dying d u e r ocuncDt mcdical con(lnio|l Dcpcndencc upon/probl € ms $iLh(chcck): Oalcoholand/orOstreetdrugs I)ifficuhy llnding \a) lronc or ro orhcrplrcc Oinsurance-rel rcd and/orOpersonal 16.) Adjustiogro sehool denands 47.) Prcblcnrsorganizing, planning. nrrkintsdccisions. or problelrl solvhS 18.) Problems \!ith balance 49.) Rcslriulcdphysical rnobilitvandior lilnitations in self-carc (drcssi g. ba ing, ctc.) 50.) Olhcf Spccif),: Use C,/,/,, B !bo!c ro iidi.xte th. Jire nost ittportdt i cnis ilon rlt o.cs fulltosc) rlrt yo! nukcd in Colum A. numbcr"I bcs c rhc &,\t inrponant problem. l ll tr Ll,c y.r/r' hNL inrDonanr. up to '5 nr ftcy'Tir nost iqDrlinr ClientlD:_ File Nunbcr: Today\Date:_/_/_ CondilionOnsciDate: / | Agc: Scx: Administration #: | 2 3 4 Disability: PleascContinue on lhe I-.rstPaee
-
Upload
mcewenkaren -
Category
Documents
-
view
225 -
download
0
Transcript of Rebab Checklist
8/7/2019 Rebab Checklist
http://slidepdf.com/reader/full/rebab-checklist 1/2
a4
)1
?
t :
2
: '
' - j
: :a
,$
Part f. in rr'.r,"*"'incal,,"' z,pul m "X" besidcthc m.in rh ingsprcvcnllngor discoura8ingyo( lromrcrurn,inglo yourregularlifestylc(indicaldnl llhc reasonsth.l applyt) yo!). Th.n,complet€ Part 2 as instrucredbrlo$.
l. ) Physicalr€strictionsin (check):
2.) l lcadaches
l.) Problenswith diziness4.) Pains.)
7 . )s. )9 . )10 . )I l . )l l . )r3 . )
Dbcnding dlifling Oseeitrgmd/or Oreaching
l: . ) I )cp.ession21.) |lnbnrrlsscdrboutdisabililydr socinldiscriminatio
l:1.)l-ackol cducat ioror sl i l lsi5.) Fc\\'j0bsavailablcin honearcr
16.) Mcnrtllf or leamingproble|ni17.) Luckof enerSy.fcelingiltigucd18.) (onr lbr lwithpresentl i lcstylc19.)Lcg.t lproblens20.)An\ietyor strcss21.) Unablelo cngnSeinsponsor hobbies
2,1.)I)angcr0l prc\ious\\'orl25.) Problcnrswirh(check):
26.) CoDcc|llrfllir problcms27.) Not suilcd$ previouswork28.)Dil ] lcultylcarmDg
ona newJob29.)ScxLll | ldif icul ly30.)Dif t lcultycngngiDgin socialnct ivir ics31.)Dcpcndenceor problenrswnh(chcck):
SpeciSIocaLion\innr ior iL) lDillicultyobtainingajob dueto my disubilityProblcnrswith nry cmployerFcrr ofr€irjury or worseningconditionI) i i l icul lyslccpingEmolionalproblemsl,rohlcnrswith (chcck);
Dislikeofprc!iousr.ork or workplaceI)ifiicnlty lindingNell-payingjobsJobsrcsso. adjusttugto chrnginSjobdcnuMs
Spcciry:Omarriagcihnrily or Olackoi support
Specifyl
OdrivinSlnd/or Olakingpublicrransportation
Omedicntionan&)r Clsideefects
' lr (xJrngUqf l l I r t rn( lur LrrarhrnellLOspeakiDsOhearingaod/orOv'sron
Onishhnres and/orOfl ashbacts
l l . )
13.)l.l. )
16 . )17.) Il|nployerdiscriminafior)38.)I ' roblcnrs! \ i !h(check):
39.) Problcnrswith (check)l
40.)PoorIngl islrski l ls
.,1I.) Acciden!-rclalcd(check):ll.) feir ol driving.\'ork cnlironment.43.) Initrbili ty/ang.r .ont.ol4.1.)Finrnci! ldi l l iculr ic\(check):45.)Scizurcs
Difficuhyndjusringto a newiobWorriedaboutlayofffearol dyingduerocuncDtmcdicalcon( lnio| lDcpcndenccupon/probl€ms$iLh(chcck): Oalcoholand/orOstreetdrugsI)ifficuhyllnding\a) lronc or ro orhcrplrcc
Oinsurance-relrcd and/orOpersonal
16.) Adjustiogro sehooldenands47.) Prcblcnrsorganizing,planning.nrrkintsdccisions.or problelrlsolvhS18.) Problems\!ith balance49.) Rcslriulcdphysicalrnobilitvandiorlilnitationsin self-carc(drcssig. ba ing, ctc.)50.) Olhcf Spccif),:
Use C,/,/,, B !bo!c ro iidi.xte th.Jire nost ittportdt i cnis ilon rlt o.cs fulltosc) rlrt yo! nukcd in Colum A.
numbcr"I bcs c rhc &,\t inrponantproblem. l ll tr Ll,cy.r/r' hNL inrDonanr.up to '5 nr ftcy'Tir nost iqDrlinr
Client lD:_File Nunbcr:Today\ Date:_/_/_ CondilionOnsciDate: / |Agc: Scx: Administration#: | 2 3 4Disability:
PleascContinueon lhe I-.rstPaee
8/7/2019 Rebab Checklist
http://slidepdf.com/reader/full/rebab-checklist 2/2
Part 3 - Degreeof Life.Role DisabilityPle$e placcan'tC'in the appropriab box under Degreeoflife Role Dis.b lty in tle largetable below. indicating hownuch your conditiotr inpails your ability to engagein thc activitics listcd bclow.
Priorities
CD
Degreeof Life-Role Disability tp"nrl
l.) Householdchores2.) Relationshipswith friends and family3.) Parcntalactivity4.) Volunteerwork or comrnunitywork5.) Relationshipwith spoutdpafoer6.) Scxualactivity7.) Sclf-sufiiciencyin d.e,ssing,eating etc.8.) Panicipationinsports,hobbics9.) Participationin social activities10.) Lcamins/studyingI l.) Rcgular cmployment12.) Ove6ll, how disablcddoyoufccl youarc?
Part 4 - Life Role Priorities
OnceyouhavecompleredPart3,plc!.{cgo backandu.\c.?rrrrmzC undcrPrioritics!o ftlr l\e/ive nos inporranrm/.T inyour lifelrsrp theonsetofyour medicalcondition.Assignthenurnber" l" to thc ,1.,l1importantlifc an4 '2" for Iheis.(r't../mostimportant,up 0o'5" for lhcff, mostimportanLln colam D, r,nicj'e whatyouthink will bethe five mosl importantmles&/)o,rtt 't.
Part5-ConditionChangel. Msrl an'X" in a box bclo*, indicadnghowyourprr5 .r, @ndition h&schegql sinc the onst of yourcondilion. A | 00%
improvement refl€crs a retrm lo how you wcrc /r),ri.a4y bcforc your condilion bcgan.
f00% 90% 80% 10% 60% 50% 4016 30t, ?09$ r0* ro+ 20*' :ros 40sn 50* 60% 70% 80* 90% t00%
2. Mark ar "X in a box belox indicating howyour.rrlrral conditionh6 chanScdsincc thc oruct ofyour condition. A I0O%improvcmc rcnecb a rctum to howyo! |'erc .notiondlly bcforcyourconditionbcgan.
f00% t0s 20% loE 40*
l0,n 20*. l0* 40%
50%
50''
60c 10q 80% 904, 100%
70.t uoq, 90* t00%
3. ln thcluturc.how muchch$ge doyouexp&t in yourconditioroEral? Indicatewilh m 'X ' in aboxbclou A I00% improvement
rcflcctri a rctum to how you were (,sall before your condition bcgan.
100% 906 E0'. 704 40% t0,t, 204 t0 60tx.
7 to 12 Morc ThanMonths I Ycar
5_
Pu1an "X" in thc appropriatcboxiDdicatingwhcDyou lhink youmay
bcwellenough1ocarryout moslof
yournormalaclivitieso. rcles.
Put o 'X" ir thc appropriate boxindicatingwhenyou think th.t youDay be well crougl to rctum bsonc typc olwort on ei0eta tull-
Ma.k wherher this would likcly be:(Put u "X itr the appropriare box
I t o 2Immediately Months
I t o 6Months
3 t o 6MonthsN/A Immcdiately
7 to 12 More ThanMoDths I Year Ncvcr
Resular Modificd
I t o 2Months
6. N/A
40* 50% 60% 70% ao% 9.)% tw*
Full Timc Part-Time
lEI/| ' IIS .@g[J. rqr h4ksber d Mdr{d6 sy<d rr. ^'ridBEnh'5!d4 rtuvrdM^tga,r@oN M2Hr{r.(e):Mr| hldiEt r{rsrM f4
