Occupational Therapy Home Assessment Request

Occupational Therapy Home Assessment Request — Form Fields

This healthcare template includes 12 fields. Request form for occupational therapy home safety and accessibility assessments. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Patient or Caregiver Email (email, required)
• Phone Number (text, required)
• Home Address (text, required)
• Reason for Assessment (dropdown selection, required) — options: Post-Surgery Recovery, Aging in Place, Disability Accommodation, Fall Prevention, Stroke Recovery, Mobility Decline, Cognitive Decline
• Home Type (dropdown selection, required) — options: Single Story House, Multi-Story House, Apartment, Condo, Assisted Living, Mobile Home
• Currently Using Mobility Aid (multiple choice, required) — options: Yes - Walker, Yes - Wheelchair, Yes - Cane, Yes - Scooter, No
• Areas of Concern (checkboxes, required) — options: Bathroom Safety, Kitchen Accessibility, Stair Navigation, Bedroom Access, Entry/Exit, Lighting, Floor Surfaces, Door Widths
• Referring Physician (text, optional)
• Insurance Provider (text, required)
• Specific Concerns or Recent Incidents (long text, required)