OCCUPATIONAL THERAPY ASSESSMENT DATA SET

Name: Therapist:
SS#: Service Cood/Guardian:
DOB: Case Manager:
Date(s) of Eval: Agency:
Background Information
Primary Language: Spoken: Understood: Used During Eval.
Mode of Communication:
Diagnosis:
Current Medications:
Relevant Medical History: Recent Surgeries/Hospitalizations?
Known Precautions: (check all that apply) Allergies Falls Dysphagia/Aspiration Behavioral
Sensory Defensiveness Other Medical
Comments:
Referral Source: Interdisciplinary Team Family Physician Other
Home Situation Lives with: Family/Relatives “family-living” model “supported-living” model
Has roommates? How Many?
Relevant Social/Cultural/Spiritual History:
Past OT – Other therapies?

Activities Client Enjoys

ISP Visions/Outcomes Summary

Habits/Daily Schedule
Client/Staff Areas of Concern
(safety/health/other)

Client/Staff “things I’d like to work on”

Client Factors and Performance Skills
SENSORIMOTOR COMPONENTS
Sensory Processing Functional Impaired (Comments, Hx., Records, Observations, Registration, Modulation, Integration, Tests)
Visual Acuity (corrective lenses?)
Visual Attention
Visual Tracking
Hearing (hearing aids?)
Tactile
Proprioception
Vestibular
Smell/Taste

Sensory Integrative Dysfunction may be present

Sensory Processing Evaluation Completed (see report or comments) Recommended In Progress
Ongoing
Perceptual Processing Comments (Hx., Records, Observations, Tests)

Body Scheme Right/Left Disc.

Position in Space Figure-Ground
Depth Perception Spatial Relations
Neuromuscular
Muscle Tone Trunk WNL’s Hypertonicity Hypotonicity Variable/ Athetoid
Left UE WNL’s Hypertonicity Hypotonicity Variable/ Athetoid
Right UE WNL’s Hypertonicity Hypotonicity Variable/ Athetoid
Posture Trunk WNL’s Kyphosis Lordosis Scoliosis
UE’s WNL’s Shoulders: Rounded Retracted
Comments:
 Support needed for function Describe:
Breath Support/ Respiratory Issues:
Motor Balance/Control Functional Impaired (Comments)
Head Control
Trunk Control
Sitting
Standing
Ambulation
Upper Extremity Active Range of Motion
Left Right
Comments Able Unable FUNCTIONAL MOVEMENT Able Unable Comments
Hand to Mouth
Touch Top of Head
Reach Behind Neck
Ext. in Arc in Front of Trunk
Reach Midback
Reach Knee
Reach Foot

ROM Strength ROM Strength

Left Right Left Right Left Right Left Right
Shoulder Flexion Wrist Flexion
Extension Extension
Abduction Fingers MCP Flexion
Int. Rot. Extension
Ext. Rot. Fingers PIP Flexion
Elbow Flexion Extension
Extension Fingers DIP Flexion
Forearm Pronation Extension
Supination Thumb Abduction
Opposition
Left Right Comments
Grip Strength lbs:
Pinch Strength Lateral
Pad
Soft Tissue integrity WNL’s Prone to Breakdown Has current Breakdown
Comments:

Endurance for Functional Activities Poor Fair WFL’s WNL’s

Comments:
Motor Control Functional Impaired
Left Right Left Right (Comments, Tests)
Object Exploration
Praxis
Crossing Midline
Bilateral Use
Reaching for Target
Isolates finger to point or poke

Voluntary Release
Utensil/Pencil Grasp

Reliable movement(s) for Switch Access:

Grasp (check all that apply) Reflexive Left Right Palmer Left Right Three Jaw Chuck Left Right
Lateral Pincer Left Right Modified Pincer Left Right Fine Pincer Left Right

Accurate reach to target of approx. dia. Left Hand: 1” 3” 6” 12” Right Hand 1” 3” 6” 12”

NAME: _____________________________________ OT ASSESSMENT DATA DATE: ___________ 2

Functional Upper Extremity (UE) Task Observation Sample (IE: holds spoon, bats at mobile, buttons small buttons, throws large ball, etc)
Task Comments:

COGNITIVE Functional Impaired (Comments, Hx., Report, Tests)

Level of Alertness
Attention to Task
Initiates Activity
Memory
Follows Directions 1 step 2 step 3 step
Familiar Routines
Solves Problems

PSYCHOSOCIAL
Self Awareness
Self Concept
Self Expression
Copes with Stress
Interest in Activities
Self Control
Aware of Others
Interacts with Others
Respects Others
General Mental Health
Sexual Expression

Occupational Performance
(Check items that apply)
Oral-Motor (eating/drinking/swallowing) Comments/Observations
Tube-fed? Dependently fed? Self-feeding? (data below)
Mealtime Plan in place? Yes No
Client Positioning: Describe W/C or chair:
Trunk :
UE/LE:
Head Neck:
General Muscle Tone:
Other:
Provider Position (if Applicable)
Hx. of Aspiration? Yes No Swallowing Study: Yes No Date: Location:
Hx. of GERD? Yes No Upper GI: Yes No Date: Location:
Results:

Weight Concerns? Yes No

Special Diet/Nutritional? Yes No
Food Consistency: Hx. Of Reflux? Yes No
Liquid Consistency: Hx of Rumination? Yes No
Rooting Bite Reflex Tongue Thrust Strong Gag Reflex Suckling Suck/swallow
Maintains food/drink in mouth Loss of food/drink
Achieves/Maintains Lip Poor Lip Closure Around spoon/cup? At rest?
Closure
No or minimal Drooling Mod/Severe Drooling At rest? During chewing?
NAME: _____________________________________ OT ASSESSMENT DATA DATE: ___________ 3
 Rotary Chewing Movements Vertical Chewing
Movements
Graded Jaw Movement Ungraded
Ant./Posterior Tongue Lateral Tongue
Movement Movement
Swallowing - Normal Delayed Repeated Swallows?
Clears Oral Cavity after Residue noted Where?
swallow
Normal Dentition Missing Teeth Edentulous? Dentures?
Oral Hygiene appears good Appears poor
Oral Hypersensitivity Oral Hyposensitivity

Behaviors - Appropriate Risky Behaviors Describe: Rate, Bite-Size, Stuffing Mouth, Binging, Rumination, etc…
Noted

Mealtime Communication Comments:

DAILY LIVING Key: 1 = Total Dependence 4 = Mod/Max Verbal or Gestural Assistance N/A = not applicable
2 = Mod/Max Physical Assistance 5 = Min. Verbal or Gestural Assistance NT = not tested/reported
SKILLS
(Note: some items may be assessed 3 = Min Physical Assistance 6 = Independent * = with Assistive Technology
per staff report)
SKILL LEVEL COMMENTS (include Assistive Technology if applicable)
EATING/DRINKING
Holds/drinks from glass/cup
Uses Straw
Maintains grasp of spoon
Scoops food
Brings food to mouth
Uses fork
Uses knife
Uses napkin
Other
Other

SKILL Level SKILL Level SKILL Level

GROOMING TOILETING HOME LIVING
Wash Face Pulls Clothing Down Pours Drinks
Brush/Comb Hair Position at/on toilet Accesses Drinks
Brush Teeth Uses toilet paper Accesses Snacks
Apply Deodorant Flushes Prepares Simple Snack
Shaving Washes Hands Prepares Simple Meal
Apply Make-up Uses Attends Helps Set Table
Other BATHING Wipes Table
DRESSING Removes Clothing Makes Bed
Shirt Washes Adequately Puts Clothing or Personal Items Away
Skirt/Pants Shampoos Hair Laundry
Dress Bathes/Showers Safely Dusting
Socks MEDICATION Other Task
Shoes Understands What Meds are for Other Task
Bra How Many/Much and when Tells Time
Underwear Takes or consumes Medications Follows Schedule
Belt Answers Phone
Fasteners Calendar Concepts
Chooses Clothing Items

COMMUNITY Level LEISURE Level * Assistive Technology utilized in Living Areas:

NAME: _____________________________________ OT ASSESSMENT DATA DATE: ___________ 4

Shopping/Finding Items Attends to items
Putting in Basket Explores items
Ids Coins Accesses Favorite Items/Activities
Pays for Items Accesses Favorite Music
Other Accesses TV or Videos
Orders at Fast Food Place Has Identified Leisure Interests
Orders at Other Restaurant Activity
Transportation Activity
Community Safety Skills
Other
Living Skills Areas – Additional Comments:
Work/Volunteer Skills
(Describe Current Work/Volunteer
Placement)
Skills:
Challenges:
* Assistive Technology:
Work Assessment
Performance Contexts
HOME ENVIRONMENT Has basic physical access Has good access to leisure skills Has good access to Home Living Activities
Has Home Environmental Access Evaluation (See Evaluation) Home Environmental Access Evaluation is Ongoing and
Additional Home Environmental Access Evaluation Recommended addressed in 6 month reports
Areas of Concern/Comments:
DAY OR WORK ENVIRONMENT Has basic physical access Has good access to work/day activities/materials
Has Day/Work Environmental Access Evaluation ( See Evaluation) Day/Work Environmental Access Evaluation is Ongoing
Additional Day/Work Environmental Access Evaluation Recommended and addressed in 6 month reports
Other Comments:

Signature: Date:

NAME: _____________________________________ OT ASSESSMENT DATA DATE: ___________ 5