Rehabilitation Functional Assessment Questionnaire
Use this form to record functional status, rehabilitation needs, and follow-up planning. Keep the title exact and consistent throughout the form.
Patient and Assessment Context
Respondent Name
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Primary Rehabilitation Focus
*
Orthopedic Recovery
Neurological Rehabilitation
Cardiopulmonary Rehabilitation
Post-Surgical Recovery
Pain Management
Mobility and Balance
Other
Current Rehabilitation Stage
*
Initial Evaluation
Early Treatment
Active Therapy
Maintenance/Follow-Up
Discharge Planning
Other
Functional Assessment
Daily Function Assessment
*
Rows
1 - No difficulty
2 - Mild difficulty
3 - Moderate difficulty
4 - Severe difficulty
5 - Unable to perform
Mobility
1
2
3
4
5
Transfers
6
7
8
9
10
Self-care
11
12
13
14
15
Balance
16
17
18
19
20
Pain interference
21
22
23
24
25
Endurance
26
27
28
29
30
Main functional limitation observed today
*
Additional notes or clinician comments
Goals and Follow-Up
Top Rehabilitation Goal
*
Follow-Up Preference
*
Please Select
Phone call
In-person visit
Telehealth/video visit
Email update
Next available review
Other
Additional Comments
Submit
Should be Empty: