University of Santo Tomas

College of Rehabilitation Sciences

Department of Occupational Therapy

OCCUPATIONAL THERAPY ADULT INITIAL EVALUATION

Name of Patient: _ ___________________________________Age / Sex: ____ __ Date of Birth: _______________________ _

Diagnosis: _____________________________________________Rehab Doctor in-charge: _______________________________
Precautions________________________ Medications:________________ Date of Initial Evaluation:_________________________

SUBJECTIVE

This is the case of ____________, a ___ y/o M/F diagnosed with ____________________. He/she was referred for
Occupational Therapy by ______________________ for the following orders: (write down doctor’s orders).

I. HISTORY OF PRESENT ILLNESS II. PAST MEDICAL HISTORY

 Medical history of the client; When, where, why was  Previous illness; family history of illness; History of
consultation made; Previous/current therapy (include medication
frequency, management received, changes noted in
functional status)

III. CHIEF COMPLAINT IV. OT GOALS

OBJECTIVE

I. RANGE OF MOTION
All joints of BUE and/or BLE are WNL/WFL upon PROM/AROM except for the following:
Difference
Joints PROM AROM Norms Cause
(N-PROM)

Functional ROM Testing:

Grade Right Left
Upper Extremities

Lower Extremities

Others

II. MUSCLE TONE III. MUSCLE STRENGTH

All major muscle groups on both (L) and ® side are considered All major muscle groups on both (L) and ® side are considered
normotonic except: WNL/WFL except:
Muscle Group Muscle Tone Muscle Group Muscle Grade

*If functional assessment was performed, indicate the activity and

the response of the client.

MUSCLE BULK
o Note any muscle bulk asymmetry and what
procedures you did to confirm such
IV. REFLEX TESTING V. OTHER PERTINENT FINDINGS
Deep Tendon Reflexes  Include all possible findings related to the condition (i.e.
shoulder subluxation, edema, hypertrophic scarring, use
of assistive devices, asymmetry, abnormal positioning,
etc)

VI. SENSORY-PERCEPTUAL SKILLS

A. SENSORY SKILLS B. PERCEPTUAL SKILLS

Sensory Sensory
Grade Stimulus Response Grade Stimulus Response
Modality Modality
Light Stereognosis
Touch
Proprioception
Pressure
Kinesthesia
Pain
R/L
2 point discrimination Discrimination
Figure Ground
Discrimination
Form
Norms Constancy
DIP 1-2 mm Spatial
MCP 3-4 mm Relations
PIP 5-6 mm Depth
Palm 7-10 mm Perception
Position in
Space

VII. COGNITIVE AND COMMUNICATION SKILLS

+/- Cognitive skills Remarks
Ability to follow ____step directions

Ability to name common objects

Orientation (G,F, P)

IX. HAND FUNCTION

HANDEDNESS: _______

GRIP STRENGTH: grade (L)___ ® ___

LEFT RIGHT
st
1 2nd 3rd 1st 2nd 3rd

AVERAGE

PINCH STRENGTH: grade (L)___ ® ___

LEFT RIGHT
PREHENSION
1st 2nd 3rd AVE 1st 2nd 3rd AVE
Lateral
Tripod
Pad to pad
Tip to tip
 RGCR PATTERNS
PATTERN RIGHT LEFT
Grading Functional Justification Grading Functional Justification
(+/-) (+/-)
REACH
GRASP
CARRY
RELEASE
GROSS PREHENSION PATTERNS FINE PREHENSION PATTERNS

GROSS FINE
LEFT RIGHT LEFT RIGHT
PREHENSION PREHENSION
SPHERICAL LATERAL

CYLINDRICAL TRIPOD
HOOK PAD-PAD
TIP to TIP

X. BALANCE AND TOLERANCE

GRADE (G,F,P) BALANCE GRADE (G,F,P) TOLERANCE

SITTING
STANDING
XI. SPECIAL TESTS
*Write the special test/s used, a short description of the test (what is it for? What are being tested? How many subtests? Scoring? Etc),
and the summarized results of the test

XII. ACTIVITIES OF DAILY LIVING

TOTAL FIM/BARTHEL SCORE: _______________ (Expound on the level of assistance)

Problem Area Score Remarks

Feeding
Dressing Upper Body
Dressing Lower Body

Toileting
Bathing
Grooming and Hygiene

ASSESSMENT:

STRENGTHS WEAKNESSES

Prognosis:

Problem List:

Prepared by: Noted by:

____________________________ ____________________________
Name of Student