Occupational Therapy Initial Evaluation

Name: ___________________________________________ Date of Evaluation: _____________

Age/Sex: ____________ Birthday: ___________________ Address:
_______________________________________
Diagnosis: _______________________________________ Contact #: _____________________________________

Precautions/Other Interventions Received:

SUBJECTIVE FINDINGS:

Informant/Primary Caregiver:

Primary Concerns: Goals:

OBJECTIVE FINDINGS:

Socio-emotional Response & General Behaviour

General Behaviour:

[ ] Cooperative [ ] Uncooperative [ ] Passive

Response to Strangers: ( + / - )

[ ] Stranger Anxiety

[ ] Separation Anxiety

Response to Name-calling:

[ ] Consistent [ ] Inconsistent [ ] Absent

Ability to Follow Instructions: [ ] Able [ ] Unable

No. of Steps and Complexity:

WORK SKILLS P F G
Attention Span
Concentration
Impulse Control
Frustration
Tolerance
Decision-making
Problem-solving

ACTIVITIES OF DAILY D A I Performance

 LIVING
Feeding

Dressing

Toileting

Bathing

Grooming

Sleep Pattern

INSTRUMENTAL ACTIVITIES OF DAILY LIVING

Leisure:

Money Management:

Home Management:

Telecommunication/Transportation:

Others:

PLAY
COGNITIVE LEVEL SOCIAL LEVEL
[ ] Sensorimotor/Exploratory [ ] Unoccupied
[ ] Symbolic [ ] Onlooker
[ ] Creative [ ] Solitary-independent
[ ] Games with Rules [ ] Parallel
[ ] Associative
[ ] Cooperative

SENSORY PERCEPTUAL/PROCESSING
Tactile [ ] Hyporesponsive [ ] Hyperresponsive
Vestibular [ ] Hyporesponsive [ ] Hyperresponsive
Proprioceptive [ ] Hyporesponsive [ ]
Hyperresponsive
Visual [ ] Localize [ ] Track
Auditory [ ] Localize [ ] Track

SENSORY PROCESSING SKILLS

BODY + -
AWARENESS/SCHEME
 Body Part Use
Body Scheme
R/L Discrimination
Position is Space
VISUAL PERCEPTUAL
SKILLS
Depth Perception
Spatial Relation
Visual Discrimination
Figure-Ground Discrimination
Form Constancy
Visual Closure
Visual Memory
Visual Sequential Memory

SCHOOL PERFORMANCE

[ ] SPED [ ] Mainstream [ ] Regular

Behaviour:

Handwriting: [ ] Trace [ ] Imitate [ ] Copy [ ] Recall

Coloring Skills:

Cutting Skills:

Cognitive Skills:

Concepts + -
Letters
Numbers
Shapes
Animals
Problem-solving Skills
Body Parts
Use of Common Objects

Other Comments:

SOCIAL PARTICIPATION

Setting Trigger Behaviour Consequence

Prevocational/Vocational Participation: