Post-Surgical Rehabilitation Assessment Form
Patient Name
Date of Assessment
Date of Surgery
Procedure Performed
Surgeon's Name
Current Complaints / Symptoms
Pain Assessment (Location, Intensity, Duration)
Mobility Status
Independent
With Assistance
Bedridden
Ambulation Aid Used
None
Cane
Walker
Crutches
Wheelchair
Range of Motion Examination
Strength Assessment
Surgical Site Observation
Swelling/Edema
Functional Limitations
Goals for Rehabilitation
Therapist's Notes