Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Occupational Therapy Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Referring Diagnosis
Self-Care ADL Assessment
Home Management Activities
Hand & Upper Extremity Concerns
Additional details
Fine Motor Skill Assessment
Workplace & Ergonomic Concerns
Pain Assessment
Current Adaptive Equipment
Prior OT / Rehabilitation History
Current Medications
| Medication | Dose | How often |
|---|---|---|
Patient Treatment Goals
Consent & Signature
Date
Occupational Therapy Intake Form template from formisoft.com. formisoft.com/intake-templates/occupational-therapy-intake