Hospital Discharge Rehabilitation Assessment Form
Complete this assessment to help determine post-discharge rehabilitation needs. All responses are confidential and do not collect sensitive identifiers.
Patient Initials
*
Date of Assessment
*
-
Month
-
Day
Year
Date
Primary Diagnosis Related to Hospitalization
*
Rate the patient's current mobility level
*
Fully dependent
1
2
3
4
Fully independent
5
1 is Fully dependent, 5 is Fully independent
Pain level at time of discharge
*
1
2
3
4
5
6
7
8
9
10
Select the main type of support available at home
*
Family/caregiver support
Professional/home health aide
No direct support
Other
Self-care ability (bathing, dressing, feeding)
*
Needs full assistance
1
2
3
4
Completely independent
5
1 is Needs full assistance, 5 is Completely independent
Cognitive status
*
Alert and oriented
Occasional confusion
Frequent confusion or memory loss
Functional Activity Assessment
*
Rows
Unable
Needs Assistance
Independent
Walking
1
2
3
Transferring (bed/chair)
4
5
6
Toileting
7
8
9
Meal preparation
10
11
12
Are additional rehabilitation services recommended?
*
Yes
No
Unsure
Submit Assessment
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