Occupational Therapy Evaluation Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender
Male
Female
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Company Name
Marital Status
Single
Married
Divorced
Widowed
Other
Please list initial complaints of the patient
When did the patient get this injuries/symptoms?
-
Month
-
Day
Year
Date
How did this injury happened, please explain
Did the patient received any medical treatment, therapy, or surgery for this?
Yes
No
Other
When did the patient start the treatment or therapy?
-
Month
-
Day
Year
Date
If the patient undergo any surgery related to this injury, please specify the date
-
Month
-
Day
Year
Date
Please rate the condition of the treatment or therapy?
Worst
1
2
3
4
Excellent
5
1 is Worst, 5 is Excellent
Please rate the pain the patient is experiencing
No Pain
1
2
3
4
5
6
7
8
9
Extremely Painful
10
1 is No Pain, 10 is Extremely Painful
Responsiveness
Alert
Lethargic
Responds to verbal expression
Reacts to painful stimuli
Non-responsive
Orientation
Name
Place
Time
Agitation
Follow commands
Responds to stimuli
Confused
Safety Awareness
Good
Fair
Poor
Please select the activities that makes the condition worse?
Sitting
Standing
Walking
Running
Resting
Bending
Sneeze
Cough
Morning
Afternoon
Evening
Medication
Other
Upper Extremities - Please list the body part and the condition. Example: Left (Good, Fair, Poor).
Rows
Body Part
Left
Right
Strength
1
2
3
4
5
Lower Extremities - Please list the body part and the condition. Example: Left (Good, Fair, Poor).
Rows
Body Part
Left
Right
Strength
1
2
3
4
5
What are the medications the patient is currently taking?
Does the patient have any allergies? Please list them below:
If the patient have been previously hospitalized, please provide the reason and the year.
Kindly check the following medical conditions that the patient have
Swallowing difficulty
Motion sickness
Stroke
Arthritis
Fever
Osteoporosis
High blood pressure
Unexplained weight loss
Anemia
Cardiovascular problems
Blood clots
Shortness of breath
HIV/Hepatitis
Epilepsy/Seizures
Smoking history
Drinking alcohol history
Diabetes
Depression/Anxiety
Myofascial pain
Fibromyalgia
Pregnancy
Other
What does patient want to achieve from therapy?
What is the current treatment plan?
What are the current clinical goals?
Physical Therapist Name
First Name
Last Name
Phone Number of Physical Therapist
Please enter a valid phone number.
Email Address of the Physical Therapist
example@example.com
Physical Therapist Signature
Date Signed
-
Month
-
Day
Year
Date
Print Form
Submit
Should be Empty: