Stroke Rehabilitation Initial Assessment Form
Patient Information
Full Name
Date of Birth
Date of Assessment
Gender
Hospital/Clinic Number
Contact Number
Medical History
Date of Stroke
Type of Stroke
Other Medical Conditions
Current Medications
Medication List
Functional Assessment
Mobility
Communication
Cognitive Function
ADLs (Activities of Daily Living)
Psychosocial Assessment
Mood/Behavior
Social Support
Assessment Summary & Plan
Clinical Impression
Rehabilitation Goals
Plan & Recommendations
Assessor Name
Position/Title