Occupational Therapy Intake Form
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Occupational Therapy Intake Form
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The Occupational Therapy Intake Form is purpose-built for occupational therapy practices, capturing the functional assessment data that occupational therapists need to develop targeted, meaningful treatment plans. This template collects patient demographics alongside a comprehensive functional evaluation covering self-care activities (dressing, grooming, bathing, feeding, toileting), home management tasks (cooking, cleaning, laundry, shopping), community participation (driving, public transportation, work, leisure activities), and fine motor skills (writing, typing, buttoning, opening containers). Each activity is rated for independence level to establish a baseline.
Designed for general occupational therapy, hand therapy, pediatric OT, neurological rehabilitation, and workplace injury recovery practices, this form includes sections for diagnosis and referral information, injury or condition onset and mechanism, hand and upper extremity assessment (grip strength history, range of motion limitations, sensory changes, edema, scar management needs), workplace ergonomic concerns, adaptive equipment currently in use, prior OT and rehabilitation treatment history, pain assessment, current medications, and treatment goals identified by the patient. The pediatric section captures developmental milestones, school performance, and sensory processing concerns when applicable.
All fields are HIPAA-compliant and structured for the occupational therapy evaluation workflow. The comprehensive pre-visit documentation allows the therapist to review the patient's functional profile before the initial evaluation, identify priority areas for intervention, and prepare appropriate assessment tools. The patient-centered goal section ensures that treatment planning aligns with what matters most to the individual in their daily life, work, and community participation.
What's included
- ADL and IADL functional independence assessment
- Hand and upper extremity evaluation checklist
- Workplace ergonomic and occupational demands assessment
- Adaptive equipment and assistive technology inventory
- Patient-identified treatment goals documentation
- Prior rehabilitation and OT treatment history
- E-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- Outpatient occupational therapy and hand therapy clinics
- Pediatric occupational therapy and sensory integration practices
- Workplace injury and ergonomic rehabilitation programs
- Neurological rehabilitation and stroke recovery centers
All form fields
16 fields across 3 pages. Customize any field after signing up.
How to use the Occupational Therapy Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Occupational Therapy Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Occupational Therapy Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 16 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Occupational Therapy Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Occupational Therapy Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Occupational Therapy Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Occupational Therapy Intake Form for your practice. Set up in minutes.
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