Comprehensive Occupational Therapy Initial Assessment Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Address: _________________ Phone: _________________
• Emergency Contact: _________________ Relationship: _________________
• Primary Care Physician: _________________ Phone: _________________
• Insurance Information: _________________

Medical History

Current Medical Conditions (check all that apply)

□ Diabetes □ Hypertension □ Heart Disease □ Arthritis □ Stroke □ Cancer □ Respiratory Issues □ Other: _________________

Surgical History

Current Medications

Functional Status Assessment

Activities of Daily Living (rate 1-5, 1=independent, 5=dependent)

• Personal Hygiene: ___
• Dressing: ___
• Feeding: ___
• Toileting: ___
• Mobility: ___

Home Environment

• Living Situation: □ House □ Apartment □ Assisted Living
• Stairs: □ Yes □ No | Number of Steps: ___
• Assistive Devices Currently Used: _________________

Chief Complaint

• Primary Reason for Seeking OT: _________________
• Duration of Symptoms: _________________
• Pain Level (0-10): ___

Goals

Authorization

Signature: _________________ Date: _________________