OCCUPATIONAL THERAPY EVALUATION

Client: [Name]
Date of birth: [Date]
Date of evaluation: [Date]
Referral: [Referral source, reason, and the question to answer]
Diagnosis: [Medical or developmental diagnosis]
Setting: [Hospital, clinic, home, school, or community]
Therapist: [Name, credentials]

OCCUPATIONAL PROFILE
Reason for referral: [Concerns in the client's or family's words]
Occupational history: [Roles, routines, work, school, leisure, valued activities]
Priorities: [What the client most wants to do, or do better]
Supports and barriers: [People, services, and personal factors that help or hinder]
Relevant history: [Medical history, medications, precautions, prior therapy]

ENVIRONMENT AND CONTEXT
Home, school, or work: [Layout, stairs, bathroom, kitchen, classroom or workspace set-up]
Equipment in use: [Adaptive equipment, mobility devices, technology]
Safety: [Hazards, falls, emergency plan, who is available to help]

OCCUPATIONAL PERFORMANCE
ADLs: [Feeding, grooming, bathing, dressing, and toileting, with the assist level and cues for each]
IADLs: [Meal preparation, medication management, home management, shopping, community mobility]
Functional mobility and transfers: [Bed, toilet, tub or shower, car, with the assist level]
Work, school, or play: [Performance in the client's main roles]
Rest and sleep: [Sleep pattern and night-time routines that affect function]

PERFORMANCE SKILLS AND CLIENT FACTORS
Motor skills: [Reach, grip, coordination, balance during tasks]
Process skills: [Attention, sequencing, organizing, problem solving during tasks]
Social interaction skills: [Communication and interaction during tasks, if relevant]
Body functions: [ROM, strength, sensation, vision, endurance, pain]
Cognition: [Orientation, memory, executive function, safety awareness]

STANDARDIZED ASSESSMENTS
Assessments used: [Name, score, and what it shows for daily function]

ASSESSMENT
Summary: [Main occupational performance problems and what is causing them]
Strengths: [What the client brings that will help]
Rehab potential: [Good, fair, or poor, and why]

GOALS
Short-term goal 1: [Occupation-based, measurable, with a time frame]
Short-term goal 2: [Occupation-based, measurable, with a time frame]
Long-term goal 1: [Occupation-based, measurable, with a time frame]
Long-term goal 2: [Occupation-based, measurable, with a time frame]

PLAN
Frequency and duration: [Sessions per week, number of weeks]
Interventions: [Occupation-based activity, ADL or IADL training, therapeutic exercise, orthoses, environmental changes, education]
Equipment and environment: [Recommendations and referrals]
Agreement: [Client, family, or caregiver agreement with the goals and plan]

Signed: [Clinician name, credentials, date and time]