Post-Illness Rehabilitation Assessment Form
Complete this form to evaluate your recovery and rehabilitation progress after illness. The Post-Illness Rehabilitation Assessment Form helps track your functional status, symptoms, support needs, and follow-up planning.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Overall Recovery Progress
*
Not recovered
1
2
3
4
5
6
7
8
9
Fully recovered
10
1 is Not recovered, 10 is Fully recovered
Current Functional Abilities
*
Rows
Independent
Needs Some Help
Dependent
Mobility
1
2
3
Self-care
4
5
6
Communication
7
8
9
Daily Activities
10
11
12
Symptoms Currently Experienced (select all that apply)
Fatigue
Pain
Shortness of Breath
Cognitive Difficulties
Mood Changes
Other
Rate the impact of symptoms on daily life
*
1
2
3
4
5
Support Needs
*
No additional support needed
Occasional assistance needed
Regular assistance needed
Professional/medical support required
Barriers to Recovery (if any)
Recommended Follow-Up Actions or Appointments
Additional Comments
Submit Assessment
Should be Empty: