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
Frequently asked questions
What questions are in the “Occupational Therapy Functional Evaluation Survey” template?
The template includes 13 ready-to-use questions, starting with: “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?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 13 questions in about 7 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
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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