About this template
An occupational therapy evaluation form is an essential diagnostic tool used by medical and rehabilitation providers to document comprehensive patient histories, current functional limitations, and clinical goals. This standardized intake form helps practitioners capture critical data regarding a patient's initial complaints, injury onset, prior treatments, pain ratings, and daily living challenges before or during their first session.
Designed for occupational therapists, physical rehabilitation centers, and outpatient clinics, this template streamlines the patient onboarding workflow. By gathering detailed information on medical conditions, current medications, allergies, and specific personal goals upfront, clinicians can prepare tailored treatment plans more effectively.
Doc2Form allows you to instantly convert and customize this comprehensive evaluation form into a live Google Form. Practitioners can effortlessly collect, organize, and review patient responses in a secure Google Sheets spreadsheet, ensuring a smooth transition from initial intake to hands-on clinical care.
Key features
- Capture complete patient demographics and contact details securely.
- Document injury history, symptom onset dates, and pain ratings.
- Record current medications, allergies, and past hospitalizations.
- Assess cognitive status, safety awareness, and physical capabilities.
- Establish clear, patient-centered rehabilitation goals from day one.
Use cases
Initial patient intake for outpatient occupational therapy clinics.
Pre-assessment documentation for home healthcare providers.
Progress evaluations and therapy goal tracking for rehabilitation pro…
Progress evaluations and therapy goal tracking for rehabilitation programs.
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Select your date of birth.
- Age (Short answer)Enter your current age in years.
- Gender (Multiple choice)Select your gender identity.
- Phone Number (Short answer)Enter your primary contact phone number.
- Email Address (Short answer)Enter your active email address.
- Home Address (Paragraph)Enter your street address, city, state, and zip code.
- Marital Status (Dropdown)Select your current marital status.
- Occupation & Company Name (Short answer)List your current job title and employer, or note if retired/student.
- Initial Complaints (Paragraph)Describe your primary symptoms, functional difficulties, or reasons for seeking therapy.
- Injury / Symptom Onset Date (Date)When did your symptoms or injury first begin?
- Injury Description (Paragraph)Briefly explain how the injury occurred or how symptoms developed.
- Pain Rating (Linear scale)Rate your current pain level from 1 (no pain) to 10 (severe pain).
- Aggravating Activities (Paragraph)What specific daily tasks or movements make your symptoms worse?
- Current Medications List (Paragraph)List all prescription medications, OTC drugs, and supplements you currently take.
- Allergies (Short answer)List any known drug, food, or environmental allergies.
- Hospitalization History (Paragraph)Note any major past surgeries, hospital stays, or significant medical conditions.
- Patient Therapy Goals (Paragraph)What specific activities or milestones would you like to achieve through occupational therapy?
- Therapist Full Name (Short answer)Name of the evaluating occupational or physical therapist.
- Date Signed (Date)Select today's date.
FAQ
How do I use this occupational therapy evaluation template?
Simply use Doc2Form to instantly generate a ready-to-use Google Form from this template, then share the link with your patients or complete it during your initial consultation.
Can I customize the questions on this form?
Yes! Once the template is created in your Google Drive, you have full control to add, remove, or modify any questions to fit your practice's specific assessment protocol.
Where are the patient responses saved?
All submissions are automatically collected and stored in a connected Google Sheets spreadsheet linked directly to your Google Form.
Is this form mobile-friendly for patients?
Yes, Google Forms automatically optimize layout and viewing for smartphones, tablets, and desktop computers alike.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.