Occupational Therapy Clinic Evaluation Form B-3

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Phone 860-848-4180
Fax 860-848-3471
Occupational Therapy Clinic Evaluation—B-3
Initial Evaluation 
Reevaluation 
Name: ___________________________________
DOB: _____________ Date: __________________
Pertinent History: _______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Previous Treatment: _____________________________________________________________________
______________________________________________________________________________________
Personal Concerns/Goals:
1.
4.
2.
5.
3.
6.
Sleep Cycle:
 Sleeps soundly
 Difficulty settling
 Wakes unsettled
 Night terrors
 Restless sleep
 Intermittent waking
 other ________________________
# of hours asleep in 24 hr. cycle_____
Duration of naps__________
Comments: ________________________________________________________________________________________
__________________________________________________________________________________________________
Nutritional Intake:
 Breast fed
 Pump/bottle
 Formula
Comments: ________________________________________________________________________________________
__________________________________________________________________________________________________
Postural Alignment/Symmetry
Report of discomfort/specific areas
Degree of discomfort, 0 (none) – 10 (significant)
Muscle Strength
Muscle Tone
5 (max resistance)
-3 Severe hypotonia
Range of Motion
1 (no resistance)
0 Normal muscle tone
+3 Severe hypertonia
WFL
Impaired
5
4
3
2
1
-3
-2
-1
0
+1
+2
+3
.docx
C:\Users\ronw.SECONNMFG\Desktop\Clinic OT Eval Form Todd Ped
Page 1 of 4
rev: 12/16/2008

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