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Run: Occupational Therapy Initial Evaluation

Occupational Therapy Initial Evaluation template for documenting the occupational profile, ADL/IADL baseline, skilled findings, goals, and plan of care in on...

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Patient and Referral Information

Patient Name (required)

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 (required)

Service Setting (required)

Occupational Profile and Reason for Referral

Primary Reason for Referral (required)

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 (required)

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? (required)

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 (required)

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 (required)

Explain why the patient requires skilled OT services rather than general assistance or self-management alone.

Goals and Plan of Care

Short-Term Goals (required)

Enter measurable goals with a functional outcome, target level, and timeframe.

Long-Term Goals (required)

Enter discharge-oriented goals that reflect meaningful occupational performance.

Treatment Frequency (required)

Planned Duration (Weeks) (required)

Planned OT Interventions (required)

Discharge Plan

Describe expected discharge disposition, support needs, or follow-up recommendations.

Consent, Disclosure, and Submission

PII and Clinical Documentation Acknowledgment (required)

Use only the minimum necessary information and follow applicable privacy requirements.

Yes No N/A

Consent to Clinical Documentation (required)

Yes No N/A

Submission Notes

Optional additional comments for the therapist or reviewer.

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Email (required)

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