Occupational therapy assessment format with sample entries
An occupational therapy assessment format from referral to recommendations, with a sample entry for each section and a free PDF download.
✓Referral to recommendations, in order
✓Sample entry for every finding
✓Works with your clinic's tests
Free · No sign-up · Saves in your browser · Built into healhab as “Comprehensive Occupational Therapy Assessment”
What's inside
Reason for Referral and Occupational Priorities
Occupational Profile
Assessment Information and Sources
Occupational Performance
Activities of Daily Living and Instrumental Activities
Fine Motor and Hand Skills
Gross Motor and Postural Participation
Visual-Motor and Visual-Perceptual Skills
+ 7 more sections
Preview · 15 sections
Comprehensive Occupational Therapy Assessment
Patient
Patient ID
Date of birth
Assessment date
Therapy
Therapist
Languages
Referred by
Reason for Referral and Occupational Priorities
Reason for referral
Occupational priorities
Occupational Profile
Roles routines interests
Strengths preferences
Family school work context
Assessment Information and Sources
Assessment methods and sources
Participation observation context
Occupational Performance
Occupation / Activity
Current Performance
Supports
Barriers
Priority
Self-care
School / work participation
Play / leisure
Home / community participation
Activities of Daily Living and Instrumental Activities
ADL IADL findings
Fine Motor and Hand Skills
Fine motor findings
Gross Motor and Postural Participation
Gross motor postural findings
Visual-Motor and Visual-Perceptual Skills
Visual motor perceptual findings
Sensory Processing and Regulation
Sensory processing findings
Regulation participation impact
Attention, Planning, and Executive Function
Attention executive findings
Environment, Equipment, and Access
Environment equipment access
Strengths, Barriers, and Functional Impact
Strengths
Barriers
Functional Impact
Clinical Summary
Clinical summary
Recommendations and Plan
recommendations
Home school environment supports
Referrals follow up
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
Reason for Referral and Occupational Priorities
Who referred and why, then the family's or client's priorities in their own words.
More guidance
State who referred, why, and the question they asked, in one or two sentences. Then write the occupational priorities in the family's or client's own words: the activities they want to do, need to do, or are expected to do. Keep the referral reason and the priorities apart, because they often differ. A school may refer for handwriting while the parents worry most about dressing in time for the school van.
2
Occupational Profile
Roles, routines, interests, languages and the people around the person.
More guidance
Describe the person's roles, routines, interests and the people around them. For a child, cover who looks after them during the day, what a weekday looks like, how they play, and which school and class they attend. For an adult, cover work, household roles, community activities and what has changed since the illness or injury. Record languages used at home and at school. Strengths and preferences belong here because they shape which activities will motivate the person later.
3
Assessment Information and Sources
Every source: interviews, observations, questionnaires and tests by name and date.
More guidance
List every source: who you interviewed, where you observed, who completed any questionnaire, and each standardised test by full name and date. Note conditions that affected performance, such as a missed nap, an unfamiliar room or working through an interpreter. Readers use this section to decide how much weight each finding deserves, so be clear about what you saw directly and what was reported to you.
4
Occupational Performance
Current performance, supports, barriers and priority for each occupation, in functional terms.
More guidance
This table carries the assessment. For each occupation, describe current performance in functional terms, the supports already in place, the barriers you observed and the family's priority. Write what the person does, how long it takes and how much help they need. Leave explanations of underlying skills to the sections that follow, so this table reads as a picture of daily life.
5
Activities of Daily Living and Instrumental Activities
How each daily task is done in this home, and how much help is needed.
More guidance
Cover eating, dressing, toileting, bathing, grooming and sleep for children, and add cooking, money, transport, medicines and household tasks for adults. Describe the level of assistance using the scale your clinic has agreed, and the setting. Record how the task is actually done in that home: eating rice with the hand, using an Indian-style toilet, bathing with a bucket and mug. Independence looks different in each of these, and the plan has to fit the household.
6
Fine Motor and Hand Skills
Grasp, hand use, strength and endurance as seen in real tasks like pencil use.
More guidance
Report grasp patterns, in-hand manipulation, hand preference, use of both hands together, strength and endurance as they show up in real tasks: holding a pencil, opening a tiffin box, tying laces, using scissors. If you used a standardised fine motor test, name it and report its results exactly as its manual requires. Describe the quality of movement and signs of fatigue as well as whether the task was completed.
7
Gross Motor and Postural Participation
How posture and movement affect sitting, stairs, play and getting around.
More guidance
Focus on how posture and gross motor control affect participation: sitting on a school bench or on the floor, climbing stairs, playground games, getting in and out of an auto-rickshaw. Describe what you saw and in which environment. Avoid a list of isolated motor findings with no link to daily activity, and refer to physiotherapy notes where they exist.
8
Visual-Motor and Visual-Perceptual Skills
Copying, tracing, puzzles and handwriting, noting the notebook ruling and script.
More guidance
Describe copying, tracing, puzzle work, finding objects in a cluttered space, and the spacing and alignment of handwriting. For school-age children, name the notebook ruling used (four-line, two-line or square) and any second script, because letter formation demands differ between English, Devanagari, Tamil and other scripts. Record test names and results only as the manual specifies.
9
Sensory Processing and Regulation
Sensory responses in specific routines, written as behaviour, with who reported them.
More guidance
Describe responses to sensory input in specific routines, and how those responses affect participation. Keep observed and reported information separate and name who reported it. Write behaviour rather than labels: 'covers ears and leaves the room when the pressure cooker whistles' tells the reader more than a category. If you used a licensed sensory questionnaire, name it and report its results only in the form its manual allows.
10
Attention, Planning, and Executive Function
How the person starts, sequences, sustains and finishes tasks, with supports used.
More guidance
Record how the person starts, sequences, sustains and finishes tasks, and how they manage transitions and changes of plan. Name the task, the setting and the support used. For adults after brain injury or stroke, note safety awareness and memory supports in tasks such as cooking or managing medicines. Keep descriptions functional and connected to the occupations in the performance table.
11
Environment, Equipment, and Access
Home, school or work setting, equipment in use and anything you could not check.
More guidance
Describe the physical and social environment where the person spends their day: home layout, seating, classroom size, bench height, noise, stairs, transport and who is available to help. List equipment already in use and its condition. Note anything you could not check yourself, and recommend a home or school visit where the environment is a major barrier.
12
Strengths, Barriers, and Functional Impact
Main strengths and barriers, each linked to an activity the family cares about.
More guidance
Bring together the main strengths and barriers from the sections above and state how each affects participation. Each row should connect a finding to an activity the family cares about. Parents often read this table most closely, so use plain words and make the strengths as specific as the barriers.
13
Clinical Summary
Your own synthesis of the findings and what they mean for participation.
More guidance
The summary is the treating occupational therapist's own synthesis and must be written and confirmed by them. Keep it short, refer back to the evidence in earlier sections, and do not introduce new findings here. Say what the findings mean for daily participation. Where the assessment was limited, for example by poor attendance or an unfamiliar setting, state that plainly so readers can weigh the conclusions.
14
Recommendations and Plan
Frequency, goal areas, supports, equipment and referrals, each tied to a finding.
More guidance
Recommend therapy frequency and duration, priority goal areas, home and school supports, equipment trials and referrals, each linked to a finding in the report. Make each recommendation specific enough that the reader knows what to do. Phrase classroom accommodations as suggestions for the school to consider. Set a review date and say what will be reassessed.
Occupational therapy assessment format with sample entries: filled sample
Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.
Reason for Referral and Occupational Priorities
Referred by class teacher for slow copying from the board. Parents' priority: 'He should get ready for school without his grandmother dressing him.'
Occupational Profile
A. lives with her parents and paternal grandparents; her grandmother manages mornings. Speaks Telugu at home and English at school. Enjoys block building and helping in the kitchen.
Assessment Information and Sources
Parent interview with mother, 45 minutes, in Tamil and English. Clinic observation across two sessions. Classroom observation, 40 minutes, during a copying task. Teacher checklist returned by email.
Occupational Performance
Self-care: puts on school shirt in about 6 minutes with help to line up buttons. Supports: mother lays clothes out in order. Barrier: small buttons. Priority: high.
Activities of Daily Living and Instrumental Activities
Eats rice and dal with right hand; spills when mixing. Mother feeds the last third of the meal. Uses Indian-style toilet with a grab rail and verbal reminders for washing.
Fine Motor and Hand Skills
Holds pencil with four fingers on the shaft and wrist bent; shakes hand out after about three lines of copying. Opens a screw-top bottle with both hands on the second attempt.
Gross Motor and Postural Participation
During floor sitting in circle time, shifts position about every minute and leans on the wall. Climbs the school stairs holding the rail, one step at a time.
Visual-Motor and Visual-Perceptual Skills
Copies 8 of 12 English capital letters within the four-line ruling; letters float above the base line. In Hindi, leaves out the top line on 5 of 10 letters.
Sensory Processing and Regulation
Mother reports he refuses haircuts and cries during nail cutting. In clinic, he explored the platform swing for 10 minutes and then joined a table task without prompting.
Attention, Planning, and Executive Function
Completed a four-step sandwich task with a picture sequence; skipped step three without it. Needed two verbal prompts to return to the task after a noise in the corridor.
Environment, Equipment, and Access
Classroom of 42 children with fixed benches; desk surface above elbow height when seated. Family lives in a second-floor flat with no lift.
Strengths, Barriers, and Functional Impact
Strength: follows a picture sequence well, which helps when learning dressing steps. Barrier: tires quickly when holding a pencil, which slows note-taking in class.
Recommendations and Plan
Weekly OT sessions for 12 weeks focusing on dressing and handwriting endurance. Trial a slanted writing board in class for 4 weeks; teacher to note copying time on Fridays.
Comprehensive OT assessment vs paediatric sensory-motor assessment
Comprehensive OT assessment
Sensory-motor and participation assessment
Scope
Every occupation: self-care, school or work, play, home and community
Sensory regulation, motor and visual-motor skills, and their effect on participation
Suits
New referrals of any age, adults after illness or injury, full re-assessments
Children referred mainly for regulation, coordination or handwriting concerns
Structure
A section for each performance area and client factor
Two findings tables plus regulation, environment and trial supports
Usual readers
Parents, doctors, schools and other therapists
Parents and teachers, often for school planning
Leads to
Occupational Participation Goal Plan
Sensory-Motor and Daily Living Goal Plan
Tips and mistakes to avoid
Do
Write the occupational profile before the skill findings, so readers see why the findings matter.
Record the languages used at home, at school and during the assessment.
Ask for short phone videos of routines, note which findings came from video, and store clips in clinic records.
In joint families, ask who actually does each routine; that person belongs in the plan.
If a school will read the report, add a short paragraph a teacher can act on.
In healhab, the Comprehensive Occupational Therapy Assessment is a Template Studio starter that clinics can adapt once.
Avoid
Listing test results without saying what they mean for any daily activity.
Mixing reported and observed information so the reader cannot tell which is which.
Using labels like 'sensory seeker' instead of describing what the child did, where and when.
Writing recommendations that cannot be traced back to any finding in the report.
About this assessment report
An occupational therapy assessment format records why the person was referred, their occupational profile, how they manage self-care, school or work and play, and what you found for motor, sensory, visual-motor and attention skills. This free template follows that order, ends with a plan, and works with whatever tests your clinic uses.
A new child or adult referral needing a full picture
A school or doctor asks for a written report
Re-assessment after a long therapy block
Handover to another therapist or centre
Read more
This is the full OT assessment report, written after the first sessions with a new child or adult. In the US it is usually called an OT evaluation, and the sections match: occupational profile, performance, client factors, environment and plan.
The assessing therapist writes it from observation, interviews, teacher reports and any licensed tests the clinic uses. The plain-language profile sits near the top, so parents, paediatricians and schools can each find their part.
Questions
What is the format of an occupational therapy assessment report?+
Most follow this order: details, reason for referral, occupational profile, sources, occupational performance, ADLs, fine motor, visual-motor, sensory processing, executive function, environment, strengths and barriers, clinical summary and recommendations. This template uses that order and ends with the therapist's sign-off.
Is this the same as an OT evaluation template?+
Yes. 'Evaluation' is the usual US term and 'assessment' the usual term in India and the UK. The sections match a US OT evaluation, and you can rename headings to suit your clinic.
Does the template include standardised tests or scoring?+
No. It is a structure for writing the report. Record any standardised test by name and date, with its results in the form its manual requires.
Is there a filled sample of this OT assessment report?+
Yes. Each section guide on this page shows a fictional sample entry, using initials only. The clinical summary has no sample, because only the treating therapist can write it.
Can I use this assessment format for adults?+
Yes. The profile and the ADL and IADL section suit adults after stroke, hand injury or surgery. Give more space to work, household roles, transport and safety, and less to school and play.
Can I download the OT assessment form as a PDF?+
Yes. Fill it in online without signing up and download a clean PDF, or print it blank as a paper form. Your draft stays in your browser.
How long should an OT assessment report be?+
Long enough to support every recommendation. A report for one concern can be short; an adult going home after a stroke needs more. Remove sections that do not apply unless your clinic marks them 'not assessed'.
