Traumatic Brain Injury Rehabilitation Assessment Form
Evaluate rehabilitation needs, current status, and therapy planning for patients following traumatic brain injury.
Patient Initials
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Injury Type
*
Mild (Concussion)
Moderate
Severe
Other
Time Since Injury
*
Please Select
Less than 1 month
1–3 months
3–6 months
6–12 months
Over 1 year
Current Symptoms (select all that apply)
*
Headache
Dizziness
Memory Problems
Difficulty Concentrating
Mood Changes
Fatigue
Sleep Disturbance
Other
Functional Status Assessment
*
Rows
Independent
Needs Assistance
Dependent
Mobility
1
2
3
Self-care
4
5
6
Feeding
7
8
9
Toileting
10
11
12
Transfers
13
14
15
Cognitive Function Rating
*
Severely Impaired
1
2
3
4
Normal
5
1 is Severely Impaired, 5 is Normal
Communication Ability
*
Normal
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Therapy Goals (select up to 3)
*
Improve Mobility
Enhance Communication
Increase Independence
Reduce Symptoms
Cognitive Rehabilitation
Other
Treatment Planning Needs
*
Please Select
Physical Therapy
Occupational Therapy
Speech-Language Therapy
Neuropsychological Support
Multidisciplinary Team
Submit Assessment
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