Mobility & Positioning

    Does participant use any assistive devices? WheelchairCrutchesWalkerShower ChairRaised Seat (chair and/or Toilet)Brace
    If participant uses a wheelchair, how do they transfer? AloneWith Assistance
    If participant uses a brace, what does it support? BackNeckLegFeet
    Can participant bear weight? NoYes
    Comments

    Social, Environmental, Verbal, Non-verbal Triggers

    ThunderstormsWords / PhrasesLoud NoisesAnimals / BugsClose Proximity to OthersSpecific People
    Please list specific instances of triggers (words, phrases, animals, bugs, people)
    Please describe what occurs with the behavior.
    What strategies or method(s) are used for calming or de-escalation?

    Toileting

    Does applicant use the a toilet appropriately? Will state needVerbal promptPhysical assistance
    Does applicant manage their own personal care (wiping)? IndependentlyVerbal PromptPhysical Assistance
    Does applicant use a catheter? No CatheterIndependentlyPhysical Assistance
    Does applicant wear absorbent briefs? No Absorbent BriefsDayNightBoth Day and Night
    Comments:

    Hygiene

    Does applicant take a shower? IndependentlyVerbal PromptPhysical Assistance
    Does applicant dry themselves? IndependentlyVerbal PromptPhysical Assistance
    Does applicant shampoo hair? IndependentlyVerbal PromptPhysical Assistance
    Does applicant brush their teeth? IndependentlyVerbal PromptPhysical Assistance
    Comments (if refusal, how to persuade):

    Communication

    Does participant communicate verbally? NoYes
    Does participant communicate using Sign Language? NoYes
    Does participant require a communication device? NoYes
    If so, does the device need to be charged? NoYes
    Device / App Name:
    Comments:

    Other Assistive Devices

    Glasses / ContactsCPAP / BIPAPNicotine ProductsHearing AidsPacemakerFidget / Special Item
    Additional devices or items (please describe):

    Nighttime Routine

    Does participant sleep through the night? NoYes
    If participant has positioning requirements, please explain:
    If participant has special sleep habits, please explain:
    If participant has a history of sleepwalking, please explain:
    If participant has history of wetting or soiling bed, please explain:
    Comments:

    Eating and Drinking

    How does applicant eat? IndependentlyVerbal PromptPhysical Assistance
    How does applicant drink? IndependentlyVerbal PromptPhysical Assistance
    If participant needs special positioning, please describe:
    If participant uses adaptive equipment, please describe:
    Comments:

    Dressing / Undressing

    How does applicant get dressed? IndependentlyVerbal PromptPhysical Assistance
    How does get undressed? IndependentlyVerbal PromptPhysical Assistance
    Comments:

    Additional Information

    If applicant uses assistive equipment, how do they care for it? IndependentlyVerbal PromptPhysical Assistance
    Does participant have seizures? NoYes
    Has the participant ever been away from home overnight? NoYes
    Does the participant do well in groups? NoYes

    Other Helpful Information

    Pleaes include any other information you feel would be helpful to camp staff or nurses: