Stroke Recovery Rehabilitation Assessment Form
Please complete this assessment to help us evaluate your rehabilitation progress and needs following a stroke.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Stroke
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Type of Stroke
*
Ischemic
Hemorrhagic
Transient Ischemic Attack (TIA)
Other
Mobility Assessment: Please rate the patient's ability to perform the following activities.
*
Rows
Independent
Needs Assistance
Dependent
Walking
1
2
3
Transferring (bed/chair)
4
5
6
Climbing Stairs
7
8
9
Standing Balance
10
11
12
Activities of Daily Living (ADL) Assessment: Please rate the patient's ability to perform the following.
*
Rows
Independent
Needs Assistance
Dependent
Bathing
13
14
15
Dressing
16
17
18
Feeding
19
20
21
Toileting
22
23
24
Cognitive Assessment: Please indicate if the patient experiences any of the following.
*
Memory difficulties
Attention or concentration problems
Difficulty following instructions
Impaired judgment
None of the above
Communication Assessment: Please select any difficulties the patient has with communication.
*
Speaking clearly
Understanding speech
Reading
Writing
None of the above
Pain Level (0 = No pain, 10 = Worst possible pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Mood and Emotional State: Please rate the patient's mood over the past week.
*
Stable/Positive
Mildly Depressed/Anxious
Severely Depressed/Anxious
Other
Additional Comments or Observations
Submit Assessment
Should be Empty: