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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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샘플 질문

템플릿에 포함된 내용을 미리 확인해 보세요. 모든 질문은 설문 공개 전에 자유롭게 수정할 수 있습니다.

질문 13개 · 약 7분
Q01
메시지

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
객관식필수

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
매트릭스필수

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

8개 행 × 5개 열
  • Bathing or showering
  • Getting dressed
  • Preparing meals or cooking
  • Eating or feeding yourself
  • Household chores (cleaning, laundry)
  • 외 3개
열: No difficulty · Mild difficulty · Moderate difficulty · Severe difficulty · Unable to do
Q04
의견 척도필수

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

척도: 0 – 10
최소:No pain at all최대:Worst pain imaginable
Q05
객관식필수

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
최선·최악 선택형(MaxDiff)필수

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
세트별 최선·최악 선택최선:Matters most최악:Matters least
Q07
의견 척도필수

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

척도: 1 – 7
최소:Not at all confident최대:Extremely confident
Q08
단문형

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

Q09
객관식

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 인터뷰

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
객관식

What is your age range?

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

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q13
메시지

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.

포함된 기능

  • AI 후속 질문

    정형화된 설문이 놓치는 세부 내용을, 주관식 답변에 맞춰 AI가 심층 질문으로 끌어냅니다.

  • 주의력 확인 장치

    성의 없는 답변과 저품질 응답자를 걸러내는 내장 안전장치입니다.

  • AI가 작성한 문안

    문구, 질문 순서, 분기 로직까지 AI가 연구 목표에 맞춰 작성합니다.

  • 자동 리포트

    응답이 모이면 주요 주제, 인용문, 이해하기 쉬운 요약이 자동으로 작성됩니다.

다른 서비스와 비교

다른 설문 도구의 가장 유사한 템플릿을 검토했습니다. 그 도구들이 잘하는 점과, 이 템플릿이 한발 더 나아가는 지점을 정리했습니다.

이 템플릿을 선택하는 이유

  • 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.

잘하는 점

  • 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)

아쉬운 점

  • 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.

잘하는 점

  • 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

아쉬운 점

  • 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.

잘하는 점

  • 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

아쉬운 점

  • 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

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