Post-accident Care Rehabilitation Assessment Form
Assess rehabilitation needs after an accident, including current symptoms, functional limitations, recovery goals, and follow-up priorities.
Accident and Recovery Background
Accident date or approximate timeframe
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Accident type or cause
*
Motor vehicle incident
Slip or fall
Sports-related injury
Work-related injury
Other
Current stage of recovery
*
Please Select
Acute phase
Early rehabilitation
Mid rehabilitation
Late rehabilitation
Ongoing management
Recovered but monitoring
Assessment type
*
Initial assessment
Follow-up review
Current Rehabilitation Status
Pain or discomfort level
*
1
2
3
4
5
Mobility level
*
Fully mobile
Slightly limited
Moderately limited
Severely limited
Unable to move independently
Other
Current activity limitations
Walking
Standing
Lifting
Bending
Driving
Self-care tasks
Work duties
Exercise
Other
Current therapies or exercises being used
Function, Goals, and Follow-up Needs
Functional Areas and Current Limitation Severity
*
Rows
Mild
Moderate
Severe
Mobility
1
2
3
Pain management
4
5
6
Self-care
7
8
9
Work tasks
10
11
12
Sleep
13
14
15
Daily activities
16
17
18
Desired Improvement for Key Activities
*
Rows
Minimal
Some improvement
Major improvement
Walking
19
20
21
Lifting or carrying
22
23
24
Standing tolerance
25
26
27
Sitting tolerance
28
29
30
Stairs
31
32
33
Hand use
34
35
36
Preferred Rehabilitation Focus Areas
Physical therapy
Occupational therapy
Pain management
Home exercise program
Work conditioning
Assistive devices
Other
Support Needed at Home or Work
Help with chores
Transportation assistance
Work schedule modifications
Ergonomic adjustments
Family/caregiver support
Temporary duty restrictions
Other
Urgency for Follow-up
*
Within 24 hours
Within 3 days
Within 1 week
Routine follow-up
Unsure
Additional Notes for the Care Team
Submit
Should be Empty: