1. Shishu Polli Plus
Tengra, Sreepur, Gazipur.
Occupational Therapy Psychosocial Assessment Form:
Part A
General Information
ID NO:
Name of client: Sex: M/F Age:
House Name:
Birth History:
Post Admission History:
Relevant Medical History:
Diagnosis:
Date:
Part B
Performance Components
1. Activities of Daily Living ( Measure by FIM Scale)
1.1: Self-care:
1.2: Productivity:
1.3: Leisure:
2. Physical presentation <overall observation>
2.1 Posture:
3. Cognitive Skill <overall observation>
2.1 Attention Span:
2.2 Organization:
2.3 Problem Solving Skill:
3. Dynamic state <overall observation>

2. 3.1 Needs:
3.2 Interest:
3.3 Emotion:
3.4 Values:
3.5 Motivation:
4. Reality testing:
5. Insight:
6. Self-Expression
7. Self- Concept <overall observation>
7.1 Identity
7.2 Sexual Identity
7.3 Body Image
7.4 Knowledge of own assets and limitation
7.5 Self Esteem (Rosenberg’s self-esteem scale.)
8. Self -Discipline
8.1 Volition:
8.2 Self- Control:
8.3 Self-Responsibility:
8.4 Dealing with adversity:
9. Concept of others:
10. Social interaction:

3. 10.1 Interpretation of situation:
10.2 Social skill
 Verbal communication
Tone:
Volume:
Pace of Speech:
 Non-verbal Communication :
Social smile
Gesture
Nodding
 Dyadic interaction
 Group interaction
10.3 Structured social <overall observation>
 Cooperation
 Compromise
 Competition
 Assertiveness
 Negotiation
Strength List:

4. Problem List:
Clinical Reasoning
 Frame of Reference:
 Model:
 Approaches:
 Techniques:
Name & Signature of therapist: Name &signature of participant:
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PrepareBy:
Syed Shakawat Hossain
PC-R&L Dev.
SPP