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Occupational Therapy Initial Evaluation - Free Healthcare Template | ZenBuild | ZenBuild

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Occupational Therapy Initial Evaluation

Gather baseline information for occupational therapy patients including functional limitations, home environment, and rehabilitation goals. Supports customized therapy planning.

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Occupational Therapy Initial Evaluation

Please complete this form so we can understand your needs and design an effective therapy program.

Patient Name*

Diagnosis or Reason for Referral*

Functional Areas Affected (select all that apply)*

Upper extremity function (arm/hand)Fine motor skillsCognitive or memory functionSelf-care (dressing, grooming, bathing)Home management tasksReturn to work or school

Living Situation*

HouseApartmentAssisted living facilitySkilled nursing facility

Do you live alone?*

YesNo — with familyNo — with caregiver

Primary Occupational Therapy Goals*

Current Adaptive Equipment or Assistive Devices Used

Template Details

CategoryHealthcare

IndustryHealthcare

Fields7

Uses0

healthcareoccupational therapyrehabilitationfunctional assessmentOT