Occupational Therapy Intake Form

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.