Client Note (Sarah)
Sarah
Client ID 048
- Name
- Sarah
- Primary Diagnosis
- Spina bifida
- Insurance
- BCBS
- Referring Physician
- D. Williams, MD
- Age
- 40
- Gender Identity
- Female
- Pronouns
- She/her/hers
- Race/Ethnicity
- White
40yo WF with spina bifida, diagnosed at birth. Underwent post-birth myelomeningocele repair. Received OT/PT throughout childhood. Does not currently receive therapy services.
Marital status:Married 3 years
Primary language:English
Current level of function:Modified independent, completing ADL/IADLs at wheelchair-level with adaptive equipment PRN, including driving with hand controls.
Employment/work/school:College education. Licensed pharmacist working full-time as the administrative coordinator for a community health clinic. Work duties involve prolonged sitting at a desk and occasional lifting up to 15 pounds.
Play/leisure/interests:Proud cat-owner. Enjoys participating in adaptive sports program activities, including wheelchair basketball and hand-cycling. Competes with husband in the wheelchair division of 5Ks, half marathons, and marathons state-wide.
Environmental factors:Lives with husband in one-story house. 1 STE with ramp, no handrails. Zero-entry shower with built-in bench, handheld shower head, grab bars. Standard toilet height with grab bars.
Gabapentin
Oxybutynin