Client Note (Jared)
Jared
Client ID 055
- Name
- Jared
- Primary Diagnosis
- SCI
- Insurance
- BCBS
- Referring Physician
- E. Hall, MD
- Age
- 43
- Gender Identity
- Male
- Pronouns
- He/him/his
- Race/Ethnicity
- White
43yo WM with SCI at C8, ASIA C, motor incomplete, sustained 12yrs ago s/p motorcycle accident. Underwent spinal decompression and fusion. Hospitalized for 3wks in acute care. D/c to inpatient rehabilitation x 7wks. Received outpatient OT/PT x 1yr.
Marital status:Married 19 years
Primary language:English
Current level of function:Modified independent to partial assist for ADLs/IADLs provided by wife. Modified independent for transfers, manual wheelchair propulsion. Drives with hand controls.
Employment/work/school:College education. Works full-time as sales associate for a wheelchair company. Work duties involve frequent travel and occasional lifting up to 10 pounds.
Play/leisure/interests:Enjoys participating in adaptive sports program activities, including wheelchair rugby, billiards, and cycling. Has weekly date nights with wife where they try new restaurants opening around town.
Environmental factors:Lives with wife in one-story house with 1 STE, ramp at entry. Zero-entry shower with shower curtain, handheld shower head, padded tub transfer bench, grab bars. Padded drop arm commode over toilet with grab bars.
Gabapentin
Baclofen
Oxybutynin