Occupational Therapy Evaluation

Reason For Referral: Evaluation and Treatment

Time Spent: 25 minutes
Pertinent History: Patient is seeking OT services to support mental health and occupational participation and
performance.

SUMMARY
Olive is a soft-spoken female freshman in college who has a history of eating disorder and diagnosed anorexia. She
expressed concern about her over-exercising habits but is dedicated to finding more interests and hobbies to fill her time
in other ways. Olive has seen recent improvement in her disorder and is positive, motivated and hopeful to make changes
in her habits.

Occupational Profile:

Activities of Daily Living and Instrumental Activities of Daily Living: ADLs and IADLs independently functioning
in and those with impairments.

Patient reports being independent in the following ADLs/IADLs: Olive expresses no deficits in any of the ADLs. She
also shows independence in all IADLs discussed such as cooking and various extracurricular activities.

Reports difficulty with the following ADLs/IADLs: Although Olive engages in all her ADLs independently, she
expressed that the IADL of cooking can sometimes be stressful due to her eating disorder. She finds herself “fighting with
food” and thinking “food is bad” but does find joy in the process of cooking.

Rest and Sleep: Activities related to obtaining restorative rest and sleep to support healthy, active engagement in
other occupations.
Olive expresses no concerns in her sleep schedule or routine. She sleeps through the night and goes to bed around the
same time every night. She feels rested in the morning and has no concerns about her sleep patterns.

Cognitive Functioning: Problem solving, attention to task, and social interaction skills to improve daily
functioning.
Olive does not exhibit any cognitive dysfunction. She participates in many social activities without struggle, does well in
her psychology courses and is interested in starting a gardening/environmental club at her college.

Sensory Functioning: Education and utilization of sensory strategies to improve coping skills and daily
functioning.
Olive did not express any sensory strategies that improve coping skills besides enjoying going out to comedy clubs. There
was some discussion about possible sensory aversions where it is was made clear she does not mind being in loud spaces
or in large venues (concerts, clubs, etc.) and enjoys being around people.

Education
Olive is freshman in college studying psychology. She expresses enjoyment in her coursework though is still getting used
to the workload difference from high school. The online format does not bother her and she recognizes the extra “liberty”
she has as a college student. She is still taking basic, foundational classes but seems hopeful and motivated by continued
studies.

Social Participation
Olive expresses the desire to find more hobbies and interests to fill her time. Through discussion with her, it is clear she
enjoys being around people. For example, going to comedy clubs is a hobby of hers, as are concerts/plays. She enjoys
being engages socially, especially with family. Through administration of the Interest Checklist, she expressed high
interest in spending time with her family playing games.

Employment/Work
Olive does not currently work or volunteer but when asked if she had any desires in this area, she spoke enthusiastically
about volunteering in a way that involved the environment (specifically gardening). She spoke about interest in starting a
gardening club at her college, too.

Preferred Leisure
Again, Olive expressed interest in finding more opportunities to engage in her interests/find new hobbies. Through
administration of the Interest Checklist, it is clear she has many interests across various domains including: playing
cards/board games, reading, gardening, music, pets, travelling and being/walking in nature. Some of these she participates
in regularly already while others she would like to find time to do more of: being around pets, travelling, gardening,
reading.

Current Stressors
Olive’s major stresses revolve around food and working out. She expresses concern involving her relationship with food, specifically
how it feels like she is “fighting” with food and how it is “bad” for her. She also expressed mild concern and stress around the amount
of school work she has.

Coping Skills or Strategies Used to Manage Stress

Olive spoke about social activities to manage her stress, specifically frequenting comedy clubs. She also expressed lots of
joy when listening to music and enjoys doing that in her free time.

Patient identified personal OT goal as:

Olive is motivated to find interests and hobbies to fill time in her day that do not involve exercise. Also, she hopes to find ways to
better organize her daily life to better fit in school work.

OBSERVATIONS AND RECOMMENDATIONS/PLAN

Occupational therapy is indicated to:
Occupational therapy is indicated to help Olive find interests and hobbies that work well with her resources and current
lifestyle as a college student. With identified interests, Olive will benefit from working to create routines that incorporate
her hobbies more, giving her motivation to stay away from the gym and structure to fit in her school work.

Goal 1: In order to better participate in healthy leisure activities, patient will spend three hours per
week being involved in at least two identified hobbies of interest by discharge.

Goal 2: To develop better time management strategies, patient will utilize paper planner to
schedule one week in advance by discharge.

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