Occupational Therapy Evaluation Worksheet

Name/Room: __________________________ Date: ________________________________

Diagnosis: Medical History:
______________________________________ _____________________________________
______________________________________ _____________________________________

Blood Pressure: __________ O2:_________ Heartrate:_________ Respirations: ____________

Precautions:____________________________________________________________________

Orientation to Name, Date, Place, Situation: _________________________________________

Pain: _________________________ (1-10): _____ ADLs FIM

Feeding
Occupational History
Prior Level of Function: Grooming

__________________________________________ Upper Body Dressing

Work/Hobbies: Lower Body Dressing
__________________________________________ Toilet
Bathroom set-up (tub or shower):
Toilet Transfer
__________________________________________
Bathing
Current Assistive Devices:
Shower/Tub Transfer
__________________________________________

MMT Right Left ROM Right Left

Shoulder Flexion Shoulder Flexion

Shoulder Extension Shoulder Extension

Elbow Extension Elbow Extension

Elbow Flexion Elbow Flexion

Forearm Supination Forearm Supination

Wrist Flexion Wrist Flexion

Wrist Extension Wrist Extension

Ulnar/radial Deviation
Notes: ________________________________
________________________________________________________________________________
________________________________________________________________________________