Home Occupational Therapy Assessment Sheet
Client Information
Name
Age
Address
Contact Number
Date of Assessment
Reason for Referral
Medical History
Functional Status
Activity
Independent
Requires Assistance
Unable
Comments
Mobility
Transfers
Personal Care
Feeding
Other
Home Environment
Description
Access (e.g. steps, lift, ramp)
Bathroom
Bedroom
Kitchen
Living Area
Other Areas
Equipment in Use
Risks or Hazards Noted
Recommendations
Assessor Details
Name
Signature
Date