Client Questionnaire for Occupational Therapy Online

Our Apologies! We Are Currently at Capacity
Due to high demand, our calendar is currently FULLY BOOKED, and we are NOT accepting new clients at this time.

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Welcome
Home Page
About
Services
Client Questionnaire
Contact
Blog
Client Log In

occupational therapist asking a client to fill out patient background information prior to OT eval

Name*

Phone number *

Email Address *

What is your Primary Therapy Need and/or Health Concern?

Age Range

Adult

Child

Preferred location of my therapy appointment

My home using my computer (Virtual)

Therapy clinic/Hospital

Do you have Insurance

Yes, i have coverage

No, i have no insurance

I don't know if i have insurance

Did your Dr./Physician recommended that you receive Occupational Therapy?

Yes, my Dr. said that I need Therapy

No, I have not spoken to my Dr. about my need for Occupational Therapy servies

Are you comfortable using technology like a computer or cell phone?

Yes, using a computer or cell phone is easy for me

No, i have difficulty and require help

What do you need help with or want to improve with Occupational Therapy services?

Selfcare skills (dressing, bathing, or eating)

Adaptive equipment (obtaining shower chair, bench, toilet commode, grab bars)

Returning to work, school or leisure activities

Fall prevention, energy conservation or home safety/accessibility

pain, joint protection/orthopedic rehab

Fine motor, basic motor skills, hand strength or coordination

Caregiver or family training

Neurologic Rehab, stroke, CVA

Pain Management

Pediatrics, Sensory integration, play or handwriting

Pelvic health, Urinary Incontenence

Therapist Preference

Male

Female

No preference

What state do you live in?

Therapist Preference or any additional requests

Info@occupationaltherapistonline.com