Q01
Message
All templatesHealthcare & 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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
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 TemplateA 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 AssessmentsA 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 TemplateA 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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