ACL Rehab Self-Assessment Form
Complete this form to review your current ACL recovery status, symptoms, and movement function. Use the same title throughout the form.
Patient Overview
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Affected Knee
*
Left
Right
Both
Surgery Date or Injury Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Recovery Status
Weeks Since Surgery/Injury
*
Current Rehab Stage
*
Post-op Week 0-6
Week 7-12
Month 3-6
Month 6+
Currently Working With a Clinician/Physical Therapist?
*
Yes
No
Symptom and Function Self-Assessment
Rate your current symptoms and function
*
Rows
1
2
3
4
5
Pain
1
2
3
4
5
Swelling
6
7
8
9
10
Stiffness
11
12
13
14
15
Stability
16
17
18
19
20
Walking tolerance
21
22
23
24
25
Stair climbing
26
27
28
29
30
Squatting
31
32
33
34
35
Balance
36
37
38
39
40
What is your biggest current limitation?
*
Walking
Stairs
Bending
Exercise
Sports
Daily activities
Other
Other limitation
Submit ACL Rehab Self-Assessment Form
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