Occupational Therapy Intake Forms & Patient Questionnaires

A physician refers a patient for occupational therapy with a diagnosis of "right wrist pain." The referral tells you almost nothing about the actual treatment needs. Is this a 35-year-old carpenter with a scaphoid fracture who needs hand therapy and work hardening to return to swinging a hammer eight hours a day, or a 72-year-old with advanced rheumatoid arthritis who cannot button a shirt, open a jar, or hold a pen? Is the patient a child with sensory processing disorder whose parents report meltdowns during teeth brushing and hair washing, or an adult recovering from a stroke who needs to relearn how to dress, bathe, and cook independently? Occupational therapy spans the entire human lifespan and addresses everything from fine motor skill development in toddlers to fall prevention in geriatric populations, and the initial intake determines which clinical pathway the evaluation follows. A generic therapy intake form does not work for OT because the scope of practice is too broad and the functional domains are too varied.

The Occupational Therapy intake form is designed for outpatient OT clinics, hospital-based rehab departments, pediatric therapy centers, and hand therapy practices. It captures the referring diagnosis and ICD-10 codes, the referring physician and their contact information, insurance authorization status (pre-auth number, authorized visits, authorization expiration date), and whether the referral is for initial evaluation or continuation of a prior episode of care. For patients transitioning from inpatient rehab or skilled nursing, it records the discharge summary findings, functional level at discharge, and the carryover goals from the prior setting — because the outpatient therapist needs to know where inpatient left off to avoid repeating assessments and wasting authorized visits.

Functional Limitations and ADL Assessment

The core of OT is function — not range of motion or strength in isolation, but what the patient can and cannot do in the context of their daily life. The intake form captures self-reported functional limitations across the major ADL (activities of daily living) categories: self-care (bathing, dressing, grooming, toileting, feeding), home management (cooking, cleaning, laundry, grocery shopping), community mobility (driving, public transportation, navigating stairs and curbs), work tasks (typing, lifting, gripping tools, sustained postures), and leisure activities (hobbies, exercise, sports, social participation). For each area, the patient indicates their current level of independence: independent, modified independent (uses adaptive equipment or compensatory strategies), requires supervision, requires minimal assistance, requires moderate assistance, or dependent. This self-report becomes the baseline against which the therapist measures progress and justifies continued treatment to the insurance carrier.

The form distinguishes between adult and pediatric patients because the functional domains differ. For children, the relevant "occupations" are play, school participation, social interaction, and self-care milestones appropriate to their developmental age. The pediatric section captures developmental history (gestational age, birth complications, developmental milestones reached and missed), current school placement (general education, resource room, self-contained classroom, homeschool), IEP or 504 plan status, and classroom concerns reported by teachers (difficulty with handwriting, scissors use, sitting in a chair, following multi-step directions, transitioning between activities, tolerating the sensory environment of the cafeteria or gymnasium). For adults, the work demands section captures the job title, physical demands classification (sedentary, light, medium, heavy, very heavy per DOT definitions), specific task requirements, and whether modified duty or workplace accommodations are available.

Hand and Upper Extremity Evaluation

Hand therapy is a subspecialty within OT, and the intake form includes a dedicated section for upper extremity conditions because they represent a large percentage of outpatient OT referrals. It captures the affected hand (dominant or non-dominant), the mechanism of injury (trauma, repetitive use, surgical, degenerative), and specific diagnoses: carpal tunnel syndrome, trigger finger, de Quervain’s tenosynovitis, lateral or medial epicondylitis (tennis elbow, golfer’s elbow), Dupuytren’s contracture, fractures (which bone, surgical or non-surgical management), tendon repair (flexor or extensor, zone, surgeon’s protocol), nerve injury (median, ulnar, radial), amputation level, and joint replacement (which joint, implant type). Post-surgical patients need the surgeon’s protocol documented at intake because the therapy progression — when to begin active motion, when to start resistive exercise, when to remove the splint — is dictated by the surgical repair, not by the therapist’s preference.

The form also captures current splint or orthosis use (resting hand splint, wrist cock-up, finger extension splint, buddy taping), wearing schedule, and compliance. Edema measurement, scar status, and wound healing stage are recorded for post-surgical and post-trauma patients. For chronic conditions like arthritis, it captures the joints affected, morning stiffness duration, current joint protection strategies, and adaptive equipment already in use (built-up handles, jar openers, button hooks, reachers).

Sensory Processing and Cognitive Screening

Sensory processing assessment is central to pediatric OT and increasingly relevant for adult populations with neurological conditions. The intake form includes a sensory profile screening that covers the seven sensory systems: visual, auditory, tactile, vestibular (movement and balance), proprioceptive (body awareness), gustatory (taste), and olfactory (smell). For each system, the form captures whether the patient demonstrates sensory seeking behavior (craves input, fidgets, mouths objects, seeks spinning or crashing), sensory avoiding behavior (covers ears, avoids certain textures or foods, resists being touched, becomes overwhelmed in busy environments), or mixed patterns. Parents of pediatric patients complete this section by indicating how their child responds to specific sensory experiences: tags in clothing, food textures, loud environments, swinging, being upside down, messy play, toothbrushing, haircuts, and nail trimming.

The cognitive screening section captures concerns related to attention, memory, executive function, and visual processing. For adult patients — particularly those recovering from traumatic brain injury, stroke, or living with progressive neurological conditions — it records orientation status, short-term memory concerns, difficulty with problem-solving or multi-step task completion, safety awareness deficits, and visuospatial difficulties (getting lost in familiar environments, misjudging distances, difficulty reading). For pediatric patients, it captures attention span, ability to follow multi-step directions, organizational skills, and whether the child has a diagnosis of ADHD, autism spectrum disorder, or a learning disability that affects therapeutic approach and goal-setting.

Intake vs. Patient Questionnaire

The intake form is the clinician’s internal document. The front desk or the evaluating therapist fills it out using the referral, the patient’s medical records, and the initial interview. It includes fields for clinical observations, assessment tool selections (COPM, FIM, DASH, Sensory Profile, BOT-2, MVPT), treatment frequency and duration recommendations, and prior authorization tracking. The companion patient questionnaire is what the clinic emails or mails to the patient (or the parent, for pediatric cases) before the initial evaluation. It asks the patient to describe their functional concerns in their own words, rate their current level of independence in daily activities, list medications, describe their home environment (stairs, bathroom setup, kitchen layout), identify their goals for therapy, and note any prior OT or PT they have received. For pediatric patients, the parent questionnaire includes developmental milestone checklists, sensory behavior inventories, school performance questions, and a section for uploading or bringing copies of IEP documents and school evaluations. Getting this completed before the first visit means the therapist can review it in advance and spend the evaluation hour on standardized testing and clinical observation rather than history-taking.

Pricing

Each form is $19.99 for the complete set (intake + questionnaire), $14.99 for intake only, or $9.99 for questionnaire only. All PDFs are fillable, HIPAA-compliant, and password-protected against editing.

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