Occupational Therapy Medical History
Personal Information
Full Name
Date of Birth
Date
Address
Phone Number
Email
Medical History
Primary Diagnosis
When Diagnosed
Other Medical Conditions
Current Medications
Allergies
Functional Abilities
Mobility
Activities of Daily Living (ADLs)
Assistive Devices/Equipment
Family & Social History
Living Arrangements
Support Systems
Employment/Education
Goals
Client Goals for Occupational Therapy