Rehabilitation Intake Form

The Rehabilitation Intake Form is designed to capture a complete clinical picture of patients entering rehabilitation programs following injury, surgery, stroke, or other medical events that have impacted their functional independence. It documents the patient's prior level of function, current functional status across multiple domains, and the specific rehabilitation goals that will guide their treatment plan. This thorough baseline assessment enables therapists and physiatrists to develop individualized care plans that target the areas of greatest need.

This template covers the full spectrum of rehabilitation assessment domains including mobility and ambulation status, activities of daily living (ADL) independence levels, cognitive function screening, communication abilities, and pain evaluation. It also captures critical contextual information such as the referring provider, diagnosis and date of onset, current medication regimen, and caregiver availability, all of which influence rehabilitation planning and expected outcomes.

Suitable for inpatient rehabilitation facilities, skilled nursing facilities, outpatient physical therapy clinics, and home health rehabilitation programs, this form aligns with CMS Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data elements. It provides rehabilitation teams with the structured documentation needed to justify medical necessity, track functional improvement over time, and coordinate seamless transitions between levels of care.