Occupational Therapy Home Visit Report
Client Details
Name
Date of Birth
Address
Phone
Report Date
Reason for Visit
Presenting Issues / Medical History
Assessments Conducted
Home Environment Overview
Living Situation
Support Network
Physical Environment (Access, Layout, Safety)
Functional Abilities
Mobility / Transfers
Activities of Daily Living (ADLs)
Communication / Cognition
Identified Risks
Recommendations
Equipment / Assistive Devices
Home Modifications
Support Services
Other Recommendations
Summary / Plan
Occupational Therapist Name
Signature
Date