Occupational Therapy Initial Evaluation

Occupational Therapy Initial Evaluation — Form Fields

This healthcare template includes 7 fields. Gather baseline information for occupational therapy patients including functional limitations, home environment, and rehabilitation goals. Supports customized therapy planning. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Diagnosis or Reason for Referral (text, required)
• Functional Areas Affected (select all that apply) (checkboxes, required) — options: Upper extremity function (arm/hand), Fine motor skills, Cognitive or memory function, Self-care (dressing, grooming, bathing), Home management tasks, Return to work or school
• Living Situation (multiple choice, required) — options: House, Apartment, Assisted living facility, Skilled nursing facility
• Do you live alone? (multiple choice, required) — options: Yes, No — with family, No — with caregiver
• Primary Occupational Therapy Goals (long text, required)
• Current Adaptive Equipment or Assistive Devices Used (long text, optional)