Senior Assessment and Data Collection Form
Patient Full Name
*
First Name
Last Name
Medical History (diagnoses, surgeries, hospitalizations, allergies)
*
Current Functional Status (mobility, transfers, endurance)
*
Activities of Daily Living (ADLs)
*
Rows
Independent
Needs Assistance
Dependent
Bathing
Dressing
Toileting
Feeding
Grooming
Transfers
Mobility
Instrumental Activities of Daily Living (IADLs)
*
Rows
Independent
Needs Assistance
Dependent
Meal Preparation
Housekeeping
Shopping
Managing Medications
Managing Finances
Transportation
Using the Telephone
Pain Assessment (location, intensity, duration, factors)
Current Pain Level (0 = no pain, 10 = worst pain)
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Balance and Gait Assessment
Strength and Range of Motion (ROM) Assessment
Cognitive Status (orientation, memory, attention, communication)
Home Safety Concerns
Equipment Needs (mobility aids, adaptive devices, etc.)
Therapy Goals
Additional Comments
Clinician Name
*
First Name
Last Name
Submit Data
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