Occupational Therapy Home Visit Assessment Form

Occupational Therapy Home Visit Assessment Form — Form Fields

This healthcare template includes 10 fields. Document patient home environment and functional abilities during OT home visits. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Home Address (text, required)
• Referring Physician (text, required)
• Primary Diagnosis (dropdown selection, required) — options: Stroke, TBI, Spinal Cord Injury, Arthritis, Hip Replacement, Parkinson's, Other
• Activities of Daily Living (ADL) Difficulties (checkboxes, required) — options: Bathing, Dressing, Grooming, Meal Prep, Transfers, Mobility, Toileting
• Home Safety Concerns Observed (checkboxes, optional) — options: No grab bars, Poor lighting, Tripping hazards, No stair railing, Cluttered walkways
• Assistive Devices Currently Used (dropdown selection, required) — options: None, Walker, Cane, Wheelchair, Grab Bars, Shower Chair, Other
• Functional Goals for Patient (long text, required)
• Recommendations and Follow-Up Plan (long text, required)