Occupational Therapy Initial Evaluation

Initial occupational therapy evaluation form to document the occupational profile, ADL and IADL baseline, clinical findings, measurable goals, and plan of care to support medical necessity for skilled OT.

Patient and Referral Information

• Patient Name
• Date of Birth
  Only collect if needed to confirm identity or support clinical documentation.
• Medical Record Number
  Optional identifier if used by your organization.
• Referring Provider
• Evaluation Date
• Service Setting

Occupational Profile and Reason for Referral

• Primary Reason for Referral
  Describe the functional problem or diagnosis-related limitation prompting OT evaluation.
• Patient Goals in Their Own Words
  Capture the patient's priorities and desired outcomes.
• Prior Level of Function
  Summarize baseline function before the current condition or decline.
• Living Situation
• Available Support System

Medical and Functional History

• Relevant Medical History
  Include diagnoses, surgeries, precautions, or other factors affecting occupational performance.
• Precautions or Restrictions
  List any weight-bearing, movement, cognitive, or safety precautions that affect treatment.
• Is Pain Present?
• Pain Level
• Cognitive or Behavioral Factors Affecting Function
  Document attention, memory, safety awareness, insight, or behavior concerns only if relevant to OT.

Baseline Occupational Performance

• ADL Baseline
  Document baseline for bathing, dressing, toileting, grooming, feeding, and functional mobility as applicable.
• IADL Baseline
  Document baseline for meal prep, housekeeping, medication management, shopping, transportation, and finances as relevant.
• Key Performance Deficits

Objective Findings and Skilled Assessment

• Upper Extremity Status
  Summarize ROM, strength, coordination, tone, edema, or other relevant findings.
• Functional Cognition
  Document attention, memory, sequencing, problem-solving, and safety awareness as they affect function.
• Environmental Barriers
  Note home or workplace barriers, equipment needs, or accessibility concerns.
• Skilled OT Justification
  Explain why the patient requires skilled OT services rather than general assistance or self-management alone.

Goals and Plan of Care

• Short-Term Goals
  Enter measurable goals with a functional outcome, target level, and timeframe.
• Long-Term Goals
  Enter discharge-oriented goals that reflect meaningful occupational performance.
• Treatment Frequency
• Planned Duration (Weeks)
• Planned OT Interventions
• Discharge Plan
  Describe expected discharge disposition, support needs, or follow-up recommendations.

Consent, Disclosure, and Submission

• PII and Clinical Documentation Acknowledgment
  Use only the minimum necessary information and follow applicable privacy requirements.
• Consent to Clinical Documentation
• Submission Notes
  Optional additional comments for the therapist or reviewer.