OCCUPATIONAL THERAPY

Initial Evaluation
(Date of IE)

I. Basic Information

Name of Child :
Nickname :
Address :
Date of Evaluation :
Date of Birth :
Age of Consult :
Diagnosis/Developmental Condition :
Occupational Therapist :
Referred by :
Source of Information :

II. Subjective Findings

Background Information:
 Doctor’s Referral (Name, a/an Age – year old, male/female was referred to Occupational
Therapy by Dr’s Name for frequency a week with the following orders: specify. )
 Family Dynamics
o Lives with and their roles?
o Who spends most of the day with child?
o Child is closest to and most compliant to?
o Who tends to spoil child and the disciplinarian?
o Disciplinary methods used at home, child’s reaction?
 Overall Performance in Occupational Areas
o General assistance given at Home
o Specified Problematic Areas
 Behaviors at Home
o Specific behaviors demonstrated at home.
 Other/s
o History of Services Received and Frequency
o Generalized Plan/Targeted Areas/Skill and Management Given
o Medication
o Brief Information on Rest/Sleep Participation

Chief Complaint:

Goals:

III. Objective Findings (ALL IN PAST TENSE)

Areas of Occupation:

Activities of Daily Living

Patient’s Name/Initial Evaluation Report Confidential. Please obtain permission for use.
 Self-care or Activities of Daily Living (ADLs) include learning how to take care of one’s body, such
as eating and feeding, dressing, bowel and bladder management, toilet hygiene, bathing and
showering, personal hygiene and grooming and functional mobility.

Occupational Area Assistance Given Remarks

Feeding and Eating
Dressing
Grooming
Toileting
Grooming

Play Participation:
Play is any spontaneous or organized activity that provides enjoyment, entertainment, amusement,
or diversion.
 Level of Social and Type of Play (Parten: Unoccupied, Onlooker, Solitary – Independent,
Parallel, Associative and Cooperative; Pratt: Exploratory, Functional, Symbolic, Dramatic,
Games with Rules and Competitive Play)
 Opportunity to play with toys, with mates, ages and frequency.
 General behavior towards playmates.
 Toys at home, favorite toys and mechanism of play.
 Storage of toys.

Social Participation:
Social participation is an organized pattern of behaviors that are characteristic and expected of an
individual or a given position within a social system.

Social Skills
 Eye contact
 Separation Anxiety
 Stranger Anxiety
 Response to Name Calling
 Response to Authority Figures/Compliance
 Joint Attention
 Include Others if Needed

Communication Skills
 Communicating Wants/Needs (Pointing, Hand leading, Crying, Shouting, Jargons,
Utterances)
 Verbal Imitation
 Name of Objects
 Listening to Instructions
 Responding to yes/no questions
 Responding to simple/complex WH questions

Client Factors:

Gross Motor Skills

 General Remarks on GMS & AGMS

Fine Motor Skills

 Hand Preference, Dominance, Handedness
 Visual Motor Integration/Coordination (Generalized)
 Coloring

Patient’s Name/Initial Evaluation Report Confidential. Please obtain permission for use.
  Handwriting
 Cutting

Work Behaviors and Emotional Regulation Skills

Skill Grading Remarks

Attention Span
Concentration
Impulse Control
Frustration Tolerance
Sitting Span

Cognitive Perceptual Skills

 General Awareness on Environment.
 Orientation to Self/People/Object
 MSRI on General Knowledge (Concepts; Colors, Shapes, Alphabets, Numbers,
Quantitative/Sizes, Body Parts Personal Data, Tool Use)
 General Visual Perceptual Skills
 Imitation of Sequences of Movements/Praxis

Other Pertinent Findings: (if necessary, delete if not)

IV. Assessment

OT Prioritized Problem List:

OT Impression (if necessary)

V. Plan

Goals: (Generalized)

OT Intervention:

Prepared by:

________________________________
NAME, OTRP
Occupational Therapist-In-Charge
PRC License No. _____

If you have any inquiries, please do not hesitate to contact the undersigned at __________
or email, _____________.

Patient’s Name/Initial Evaluation Report Confidential. Please obtain permission for use.