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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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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

13 questions · ~7 min
Q01
Message

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. It takes about 5-6 minutes, and there are no wrong answers.

Q02
Multiple ChoiceRequired

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
MatrixRequired

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

8 rows × 5 columns
  • Bathing or showering
  • Getting dressed
  • Preparing meals or cooking
  • Eating or feeding yourself
  • Household chores (cleaning, laundry)
  • +3 more
Columns: No difficulty · Mild difficulty · Moderate difficulty · Severe difficulty · Unable to do
Q04
Opinion ScaleRequired

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

Scale: 0 – 10
Min:No pain at allMax:Worst pain imaginable
Q05
Multiple ChoiceRequired

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
Best–Worst Trade-off (MaxDiff)Required

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
Pick best & worst per setBest:Matters mostWorst:Matters least
Q07
Opinion ScaleRequired

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

Scale: 1 – 7
Min:Not at all confidentMax:Extremely confident
Q08
Short Text

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

Q09
Multiple Choice

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 Interview

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
Multiple Choice

What is your age range?

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

What is your gender?

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

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.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • 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.

What it does well

  • 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)

Where it falls short

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

  • 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

Where it falls short

  • 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

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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