Occupational Therapy Intake

Occupational Therapy Intake — Form Fields

This healthcare template includes 8 fields. Collects functional ability and daily living challenges for new occupational therapy patients. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Referring Physician (text, optional)
• Primary diagnosis or reason for referral (long text, required)
• Activities of daily living you have difficulty with (checkboxes, optional) — options: Dressing / grooming, Bathing, Meal preparation, Writing / fine motor tasks, Driving, Work tasks, Mobility in home
• Overall level of independence at home (dropdown selection, required) — options: Independent, Minimal assistance, Moderate assistance, Maximum assistance
• Treatment goals — what do you hope to achieve? (long text, required)
• Additional notes or concerns (long text, optional)