Amputee Rehabilitation Progress Tracking Form
Patient Name
Date of Assessment
MRN / ID
Level of Amputation
Transfemoral (Above Knee)
Transtibial (Below Knee)
Transhumeral
Transradial
Partial Foot/Hand
Other
Limb Side
Right
Left
Bilateral
Cause of Amputation
Date of Amputation
Current Stage
Pre-prosthetic
Prosthetic Fitting
Ambulation Training
Maintenance
Stump Condition
Pain Assessment (VAS / Description)
Strength & ROM
Skin Integrity
Mobility Status
Bedridden
Wheelchair Mobile
Walking with Aid
Independent Walking
Assistive Devices Used
Type of Prosthesis
Therapy Programs (details)
Patient's Functional Goals
Progress Notes
Next Review / Follow-up Date
Therapist / Clinician Name