In-Home Occupational Performance Evaluation Form
Please complete this form to assess the client's occupational performance within their home environment.
Client Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Reason for Evaluation
*
Initial assessment
Progress review
Discharge planning
Other
Self-Care Activities (ADLs) Performance
*
Rows
Independent
Needs Assistance
Dependent
Bathing
1
2
3
Dressing
4
5
6
Grooming
7
8
9
Toileting
10
11
12
Feeding
13
14
15
Instrumental Activities of Daily Living (IADLs) Performance
*
Rows
Independent
Needs Assistance
Dependent
Meal preparation
16
17
18
Household management
19
20
21
Medication management
22
23
24
Transportation
25
26
27
Financial management
28
29
30
Home Environment Safety
*
1
2
3
4
5
Mobility Within the Home
*
Independent
Needs Assistance
Requires Assistive Device
Dependent
Use of Assistive Devices
None
Walker
Wheelchair
Grab bars
Other
Social Participation Level
*
Very Low
1
2
3
4
Very High
5
1 is Very Low, 5 is Very High
Summary of Findings and Recommendations
*
Submit Evaluation
Should be Empty: