Assessment Form - Comfy Splints 2026

1. Click ‘Get Form’ to open the Assessment Form - Comfy Splints in the editor.
2. Begin by entering the patient’s name and HICN # in the designated fields at the top of the form.
3. Fill in the facility name, address, primary diagnosis, and secondary diagnosis as applicable.
4. Indicate the prognosis by selecting 'Good', 'Fair', or 'Poor' from the options provided.
5. Complete the mobility section by choosing between 'Ambulatory', 'Wheelchair Confined', or 'Bed Confined'.
6. In the communication section, select whether the patient can make their needs known or is unable to do so.
7. Assess upper extremity (U.E.) sensation and active/passive range of motion (ROM) by selecting from the given options.
8. Document any specific treatment goals related to wrist drop, contractures, pain management, and hygiene deficits in the comments section.
9. Finally, ensure that an O.T. / P.T. signature is included along with date and contact information before saving your completed form.

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