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Healthcare & Clinical

Occupational Therapy Functional Evaluation Survey

A pre-treatment or progress-check survey for occupational therapy clients that maps real difficulty with daily living tasks, pain during activity, need for assistance, and personal priorities for regaining independence. An AI follow-up interview digs into the single hardest task to surface what's really blocking it and what a good outcome would look like, giving therapists richer intake data than a checklist alone.

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設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全13問・約7分
Q01
メッセージ

Welcome! This short evaluation helps your occupational therapist understand how your condition affects your everyday activities so they can build a plan around what matters most to you. Your responses are completely confidential and anonymized. It takes about 5-6 minutes, and there are no wrong answers.

Q02
選択式必須

What is the main reason you're seeking occupational therapy right now?

  • Recovering from surgery
  • Recovering from an injury or fall
  • Managing a chronic condition (e.g., arthritis, stroke, MS)
  • A new diagnosis affecting daily function
  • Workplace or repetitive strain injury
  • Developmental or pediatric concern
  • General decline in independence with age
Q03
マトリクス必須

In the last 2 weeks, how much difficulty have you had with each of the following activities?

8行 × 5列
  • Bathing or showering
  • Getting dressed
  • Preparing meals or cooking
  • Eating or feeding yourself
  • Household chores (cleaning, laundry)
  • ほか3件
列: No difficulty · Mild difficulty · Moderate difficulty · Severe difficulty · Unable to do
Q04
オピニオンスケール必須

At its worst in the last week, how much pain or discomfort did you feel while doing daily activities?

スケール: 0 – 10
最小:No pain at all最大:Worst pain imaginable
Q05
選択式必須

In the last 30 days, how often have you needed help from another person to complete daily tasks?

  • Never
  • Rarely (a few times)
  • Sometimes (weekly)
  • Often (most days)
  • Always (every day)
Q06
ベスト・ワースト選択（MaxDiff）必須

Which of these matter most to you right now for regaining independence, and which matter least?

  • Bathing and dressing on my own
  • Preparing my own meals
  • Returning to work or school tasks
  • Driving or getting around independently
  • Fine motor tasks (writing, buttons, utensils)
  • Moving safely around my home
  • Getting back to hobbies or leisure activities
  • Sleeping and getting in/out of bed without help
各セットで最も良いもの・最も悪いものを選択最も良い:Matters most最も悪い:Matters least
Q07
オピニオンスケール必須

How confident are you that you'll be able to manage your daily tasks independently a month from now?

スケール: 1 – 7
最小:Not at all confident最大:Extremely confident
Q08
自由回答（短文）

In your own words, what would a successful outcome from therapy look like for you?

Q09
選択式

Are you currently using any of the following at home?

  • Grab bars or shower seat
  • Cane, walker, or wheelchair
  • Reacher, dressing stick, or other adaptive tool
  • Home modifications (ramps, railings, widened doorways)
  • Someone living with me who helps regularly
Q10
AIインタビュー

Identify the single activity the respondent rated as most difficult or most important to regain, and dig into specifics: what exactly makes it hard (pain, weakness, coordination, fear of falling, environment), what they've already tried, and what a realistic 'win' would look like in the next few weeks. If they said they need help 'always,' probe what a typical day looks like and where the biggest bottleneck is.

Q11
選択式

What is your age range?

  • Under 18
  • 18-34
  • 35-49
  • 50-64
  • 65-79
  • 80 or older
  • Prefer not to say
Q12
選択式

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q13
メッセージ

Thank you for sharing this — it goes directly to your occupational therapist to help shape a plan built around your priorities and daily reality, not just a checklist.

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Goes beyond a static checklist with a matrix of daily-living difficulty ratings, a pain-during-activity scale, and a frequency-of-assistance question to map real functional status
  • Uses a max-diff exercise to surface which independence priorities matter most to the client, not just a list of options
  • Includes an AI follow-up interview that digs into the single hardest-rated activity to uncover what's actually blocking it and what a good outcome would look like, giving therapists richer intake data than a form alone
  • Pairs quantitative scales with an open-ended 'what would success look like' question, then routes everything into a report the therapist can act on directly

Jotform

Occupational Therapy Evaluation Form Template

A fielding-ready static form template covering standard OT evaluation fields, built on Jotform's drag-and-drop form builder. It's designed for one-time data capture rather than an interactive assessment. No mechanism for probing deeper into any single response.

優れている点

  • Ready-to-use template within a widely adopted form builder
  • Likely customizable fields and layout via Jotform's editor
  • Easy integration with Jotform's broader form ecosystem (e.g. e-signatures, file uploads)

物足りない点

  • Static question set with no adaptive follow-up into whichever task the client finds hardest
  • No built-in voice interview option or guided screen-share task
  • No automated per-response quality scoring or transparent AI prompt methodology

SurveySparrow

Occupational Therapy Evaluation Form Template | Pediatric OT Assessments

A conversational-style form template, though its framing leans toward pediatric OT assessments specifically rather than general adult pre-treatment or progress-check evaluation. It offers a chat-like respondent experience but is still a fixed question flow.

優れている点

  • Conversational UI that may feel friendlier than a traditional form
  • Template geared toward a specific OT sub-population (pediatric)
  • Part of a broader survey platform with reporting/dashboard features

物足りない点

  • Pediatric framing may not suit general or progress-check OT evaluations without heavy editing
  • No adaptive AI interview to dig deeper into a client's hardest task
  • No per-response quality scoring or transparent prompt disclosure

Typeform

Occupational Therapy Consultation Form Template

A polished, conversational one-question-at-a-time template suited to initial consultation intake. It's a fixed-path form rather than an evaluation instrument with adaptive probing, and is framed around consultation/intake rather than functional progress tracking.

優れている点

  • Clean, well-designed one-question-at-a-time respondent experience
  • Good fit for initial consultation/intake rather than deep clinical evaluation
  • Backed by Typeform's established design and logic-jump tooling

物足りない点

  • No adaptive follow-up interview to explore the client's single hardest activity in depth
  • No voice AI interview or guided task with screen share option
  • No automated quality scoring of responses or transparent prompt-level methodology

よくあるご質問

「Occupational Therapy Functional Evaluation Survey」テンプレートにはどのような設問が含まれていますか？

すぐに使える設問が13問含まれており、最初の設問は次のとおりです：「Welcome! This short evaluation helps your occupational therapist understand how your condition affects your everyday act…」・「What is the main reason you're seeking occupational therapy right now?」・「In the last 2 weeks, how much difficulty have you had with each of the following activities?」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか？

回答者は通常、13問を約7分で回答し終えます。

テンプレートは編集できますか？

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか？

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか？

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

このテンプレートを使う無料で始める

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