Occupational Therapy Assessment

Purpose of Assessment
The purpose of this assessment is to determine your functional abilities in regards to managing your activities of daily living
(ADLs) and instrumental activities of daily living (IADLs). ADLs include such things as hygiene, meal preparation, budgeting and
household management. IADLs include such things as use of public transport and orientation and familiarity with places like the
grocery store and bank. This assessment will help to identify your strengths and weaknesses in these and other areas and will be used
to develop a treatment plan, a potential discharge plan and to coordinate services as they relate to educational, vocation and leisure
needs.
By engaging in this assessment you can help the team to identify where you need additional supports. You can show your
treatment team that you are engaged in your rehabilitation and are working towards discharge. You may be given feedback that
identifies areas of weakness or limitations with which you may or may not agree. This feedback is required in order to provide you
with the best care and plan moving forward. The results of this assessment will be shared with you and the other members of your
treatment team. In order to participate in this assessment you must give your consent to do so, by signing below.
Screen
Vision
Reading
Hearing
Speech
Writing
Walking (tolerance in mins, barriers)
Standing (tolerance in mins, barriers)
Sitting (tolerance in mins, barriers)
Self-Care
1. Do you have any difficulties with your self care?
(Do you have problems keeping yourself clean and tidy? Does anyone need to remind you?)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
3. Are you satisfied with your self-care? ( Yes No Unknown)
5. How often do you do the following? (Explain.)
Grooming (Hair, face)
_____________
Oral Care
_____________
Bathing/Showering
_____________
Toileting
_____________
Personal Device Care
_____________
Feeding/ Eating
_____________
Medication Routine
_____________
Clothing Care
6. Do you do your own laundry?
Care of Living Environment
7. Do you have any difficulties in looking after your own living environment?
(Are you able to look after your room/home? Does anybody help you?)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

8. Can you operate the following appliances/complete the following tasks? Follow each question by asking client a quick
overview of how to operate where necessary to verify that they are familiar with use.
Microwave
Small appliances (blender, toaster, can opener)
Cook simple foods on the stove
Cook complex foods on the stove
Make simple foods requiring no cooking (sandwiches, salads)
Clean kitchen surfaces
Place dirty clothes in proper place
Washes dishes (by hand or dishwasher)
Washer/ dryer
Make own bed
Clean bedroom weekly (sweep/mop floor, tidy up)

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No

9. How much help do you receive from services with managing your living environment?
None Low help Moderate help High help Unknown
10. Overall, are you satisfied with your own living environment or the help that you are receiving in maintaining this space?
( Yes No Unknown)
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Daily Activities
13. Do you have difficulty with engaging in regular, appropriate daytime activities?
(How do you spend your day? Do you have any programs? Do you have enough to do?)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
15. Describe for me your daily/weekly routine. (Meal times, medication times, groups, leisure, vocational, education, socialization,
sleep, hygiene, etc.)
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17. Overall, are you satisfied with your daily/weekly routine? ( Yes No Unknown)
Social Functioning
19. Do you need help with social contact?
(Are you happy with your social life? Do you initiate social contact independently?)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
20. How frequently do you have social contact?
(Do you wish you had more contact with others?)
____________________________________________________________________________________________________________
23. What are your leisure interests or hobbies? (Past and Present)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Money Management
27. Do you need assistance in budgeting your money?
(Do you manage to pay your bills? Do you run out of money part way through the month?)
____________________________________________________________________________________________________________
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28. How much help do you receive from others in managing your money?

29. Overall, are you satisfied with the amount of help you are receiving in managing your money?
____________________________________________________________________________________________________________
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42. What types of work/volunteering/school do you wish to pursue?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Memory/Orientation
55. How would you currently rate your memory and ability to orient yourself? (ex. Appointments)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
56. How do you find your sleep?
57. Where do you feel the most pain?
58. What are some ways that help you decrease your pain?
Other
Other health professionals? (PT, SW, Family physician, psychiatrist, psychologist, massage therapist, specialist, etc.)