Neurological Evaluation Rehabilitation Assessment Form
Please complete this assessment to help us evaluate key areas of neurological function and rehabilitation progress.
Patient Orientation
*
Oriented to person, place, and time
Oriented to person and place only
Oriented to person only
Disoriented
Mobility Level
*
Independent
Requires assistive device
Requires assistance
Unable to mobilize
Muscle Strength Assessment
*
No movement
0
1
2
3
4
Normal strength
5
0 is No movement, 5 is Normal strength
Balance Evaluation
*
1
2
3
4
5
Coordination Test Results
*
Normal
Mild impairment
Moderate impairment
Severe impairment
Pain Level (at rest)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Activities of Daily Living (ADL) Assessment
*
Rows
Independent
Needs Assistance
Dependent
Feeding
1
2
3
Dressing
4
5
6
Bathing
7
8
9
Toileting
10
11
12
Cognitive Function
*
Severely impaired
1
2
3
4
No impairment
5
1 is Severely impaired, 5 is No impairment
Communication Ability
*
Normal
Mild difficulty
Moderate difficulty
Severe difficulty
Additional Comments or Observations
Submit Assessment
Should be Empty: