Patient Rehabilitation Progress Assessment
Please complete this form to assess and document the rehabilitation progress of the patient.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Diagnosis/Reason for Rehabilitation
*
Current Pain Level (0 = No pain, 10 = Worst pain possible)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Functional Abilities Assessment
*
Rows
Independent
Needs Assistance
Dependent
Mobility (walking, transfers)
1
2
3
Self-care (dressing, bathing)
4
5
6
Communication
7
8
9
Cognitive function
10
11
12
Mobility Progress Since Last Assessment
*
Significant improvement
Moderate improvement
No change
Declined
Therapy Goals (select all that apply)
*
Increase mobility
Improve balance
Enhance self-care skills
Reduce pain
Other
Clinician's Observations and Recommendations
*
Clinician Signature
*
Submit Assessment
Submit Assessment
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