Occupational Therapy Goals Assessment

Occupational Therapy Goals Assessment — Form Fields

This healthcare template includes 9 fields. Patients and therapists collaboratively document functional goals for occupational therapy treatment. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Referring Physician (text, required)
• Diagnosis (text, required)
• Primary Area of Concern (dropdown selection, required) — options: Upper Extremity Function, Activities of Daily Living, Cognitive Rehabilitation, Pediatric Development, Workplace Ergonomics
• Goals for Therapy (checkboxes, required) — options: Dressing Independently, Returning to Work, Driving, Home Management, Handwriting, Meal Preparation
• Current Functional Independence Level (rating, required)
• Patient-Stated Goals (long text, required)
• Target Completion Date (text, optional)