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.
