Disability Assessment Form

Disability Assessment Form — Form Fields

This healthcare template includes 8 fields. Collects functional ability and disability-related information for clinical assessments. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Referring Provider (text, optional)
• Describe your primary disability or health condition (long text, required)
• Areas affected by disability (checkboxes, optional) — options: Mobility / walking, Vision, Hearing, Cognitive / memory, Communication / speech, Self-care / activities of daily living
• Level of independence for daily activities (dropdown selection, required) — options: Fully independent, Needs some assistance, Needs significant assistance, Fully dependent
• Are you currently receiving any disability-related services? (multiple choice, required) — options: Yes, No
• Additional comments or accommodation requests (long text, optional)