Senior Care Rehabilitation Assessment Form
Use this form to evaluate and document key aspects of a senior care rehabilitation case. Please complete each section based on your professional assessment.
Resident First Name
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mobility Status
*
Rows
Current Ability
Bed Mobility
1
Transfers
2
Ambulation
3
Stairs
4
Self-Care Ability
*
Rows
Independent
Needs Assistance
Dependent
Dressing
5
6
7
Bathing
8
9
10
Toileting
11
12
13
Feeding
14
15
16
Cognitive Status
*
Alert and Oriented
Mild Impairment
Moderate Impairment
Severe Impairment
Mood and Behavior
Stable
Occasional Changes
Frequent Changes
Pain Level (0 = No Pain, 10 = Worst Possible Pain)
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Rehabilitation Progress
*
1
2
3
4
5
Comments or Notes
Submit Assessment
Should be Empty: