Burn Recovery Rehabilitation Assessment
Comprehensive evaluation of patient progress and rehabilitation needs after burn injury.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
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.
Date of Burn Injury
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Burn Location(s)
*
Face/Head
Neck
Arms/Hands
Torso
Legs/Feet
Other
Degree of Burn
*
First Degree (Superficial)
Second Degree (Partial Thickness)
Third Degree (Full Thickness)
Mixed
Current 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
Functional Assessment
*
Rows
Independent
Needs Assistance
Dependent
Mobility (Walking)
1
2
3
Self-Care (Dressing, Bathing)
4
5
6
Feeding
7
8
9
Transfers (Bed/Chair)
10
11
12
Range of Motion (ROM) Limitations
*
Shoulder
Elbow
Wrist/Hand
Hip
Knee
Ankle/Foot
No Limitations
Psychosocial Impact (select all that apply)
Anxiety
Depression
Body Image Concerns
Social Withdrawal
No Significant Impact
Current Rehabilitation Interventions (select all that apply)
Physical Therapy
Occupational Therapy
Splinting
Pressure Garments
Scar Management
Other
Rehabilitation Goals
Assessor/Provider Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Assessment
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