Rehabilitation Plan Template

Rehabilitation Plan Template

[Patient / Client Full Name]
[Street Address]
[City, State/Province, ZIP/Postal Code]
[Phone Number]
[Email Address]
Date of Birth: [MM/DD/YYYY]

1. Case and Injury Information

Type of Matter (check or describe):

• Motor vehicle accident (may include DUI-related)

• Workplace injury

• Slip-and-fall / premises incident

• Sports or recreational injury

• Post-surgical rehabilitation

• Other personal injury or medical condition: [Describe]

Date of Injury / Surgery: [MM/DD/YYYY]
Location of Incident (if applicable): [City, State/Province]

Insurance Company (if applicable): [Name]
Claim / Policy Number: [Number]

Attorney / Law Firm (if applicable): [Name]
File / Case Number: [Number]

2. Diagnosis and Current Functional Status

Primary Diagnosis (from medical provider):
[Example: “Lumbar sprain/strain,” “Rotator cuff tear – right shoulder,” “ACL reconstruction – left knee,” “Concussion,” etc.]

Secondary Diagnoses (if any):
[Diagnosis 2]
[Diagnosis 3]

Body Part(s) Affected:
[Example: neck, lower back, right shoulder, left knee, etc.]

Current Symptoms (brief description):
[Free-text: pain type and location, stiffness, weakness, limited range of motion, headaches, dizziness, etc.]

Pain Level (0–10 scale; 0 = no pain, 10 = worst pain imaginable):
Average Daily Pain: [0–10]
Worst Pain Episodes: [0–10]

Current Functional Limitations (check and describe):

• Difficulty walking or standing – [Describe]

• Difficulty sitting for long periods – [Describe]

• Difficulty lifting, carrying, pushing, or pulling – [Describe]

• Difficulty using arms or hands for reaching, gripping, or overhead tasks – [Describe]

• Difficulty with stairs or uneven surfaces – [Describe]

• Difficulty sleeping or resting – [Describe]

• Difficulty concentrating or with screen time – [Describe]

• Other limitations: [Describe]

3. Rehabilitation Team

Primary Treating Provider:
Name: [Name]
Specialty: [e.g., Primary Care, Orthopedics, Neurology, Rehabilitation Medicine]
Facility: [Clinic / Hospital Name]
Phone: [Phone Number]

Therapy / Rehabilitation Providers (list all that apply):

Provider 1:
Type: [Physical Therapy / Occupational Therapy / Speech Therapy / Chiropractic / Counseling / Other]
Name: [Provider Name]
Facility: [Facility Name]
Frequency (planned): [e.g., 2 times per week for 8 weeks]

Provider 2:
Type: [Type]
Name: [Provider Name]
Facility: [Facility Name]
Frequency (planned): [Details]

[Add additional providers as needed.]

4. Rehabilitation Goals

4.1 Short-Term Goals (Next 4–8 Weeks)

Short-Term Goal 1:
[Example: “Reduce average daily back pain from 7/10 to 4/10.”]

Short-Term Goal 2:
[Example: “Improve ability to walk for 10–15 minutes without significant increase in pain.”]

Short-Term Goal 3:
[Example: “Increase shoulder range of motion to reach shelf at chest height.”]

Additional Short-Term Goals (optional):
[Goal 4]
[Goal 5]

4.2 Long-Term Goals (Next 3–12 Months)

Long-Term Goal 1:
[Example: “Return to light-duty work with defined lifting limit,” “Resume driving safely,” “Return to recreational walking or low-impact exercise 3–4 times per week.”]

Long-Term Goal 2:
[Example: “Perform normal household tasks (laundry, basic cleaning, shopping) with manageable discomfort only.”]

Long-Term Goal 3:
[Example: “Improve overall strength and endurance to pre-injury or near pre-injury level.”]

Additional Long-Term Goals (optional):
[Goal 4]
[Goal 5]

5. Treatment and Therapy Plan

List the main types of rehabilitation planned and how often they will occur.

Clinical Treatments and Therapy (check and describe):

• Physical therapy (PT) – [Goals, focus areas, e.g., range of motion, strengthening, gait training]

• Occupational therapy (OT) – [Focus, e.g., daily activities, work-related tasks]

• Chiropractic care – [Frequency and main focus areas]

• Massage or manual therapy – [Frequency and purpose]

• Pain management (injections, procedures) – [Type and frequency if known]

• Speech or cognitive therapy – [Goals and frequency]

• Counseling or psychological support – [Focus, such as anxiety, trauma, adjustment]

• Other treatments (e.g., acupuncture, aquatic therapy): [Describe]

Planned Treatment Frequency (example structure):

• Weeks 1–4: [e.g., PT 2x/week, OT 1x/week]

• Weeks 5–8: [e.g., PT 1x/week, home exercise emphasis]

• Weeks 9–12: [e.g., re-evaluation, tapering visits as appropriate]

6. Home Exercise and Self-Care Program

Describe exercises and self-care recommended by your provider or therapist.

Home Exercises (list key items):

• Exercise 1: [Name/description, e.g., “Supine knee-to-chest stretch – 2 sets of 10, twice daily”]

• Exercise 2: [Description]

• Exercise 3: [Description]

• Exercise 4: [Description]

Activity Guidelines:

• Recommended daily walking / movement: [e.g., “Short walks 3–4 times per day as tolerated”]

• Stretching routine: [e.g., “Gentle stretching morning and evening”]

• Strengthening progression: [e.g., “Light resistance exercises 3 times per week as directed by PT”]

Self-Care Measures:

• Pain management at home (cold/heat, rest, positioning): [Describe]

• Sleep and rest recommendations: [Describe]

• Use of braces, supports, or assistive devices (cane, walker, sling): [Describe]

• Lifestyle changes (weight management, smoking cessation, stress reduction, etc., if relevant): [Describe]

7. Work, School, and Activity Restrictions

Current Work / School Status:

• Off work / school

• Light duty / modified duty

• Full duty with restrictions

• Full duty / no restrictions

• Not employed / not in school

Employer / School Name: [Name]
Job Title / Role: [Title]

Medical Restrictions (as provided by doctor or therapist):

• No lifting over [] lbs / [] kg

• No repetitive bending or twisting

• No overhead lifting or reaching with [left / right / both] arm(s)

• Limit standing to [___] minutes at a time

• Limit sitting to [___] minutes at a time, with breaks

• No driving until cleared by provider

• Light-duty only (describe permitted tasks): [Description]

• Other restrictions: [Describe]

Estimated Duration of Restrictions (subject to change with recovery):

• 0–4 weeks

• 4–8 weeks

• 2–6 months

• Ongoing / to be reassessed at follow-up

8. Progress Tracking and Review

Planned Progress Review Dates (with provider or therapy team):

• Review 1: [MM/DD/YYYY] – [Provider/Therapist]

• Review 2: [MM/DD/YYYY] – [Provider/Therapist]

• Review 3: [MM/DD/YYYY] – [Provider/Therapist]

Measures Used to Track Progress (check and describe):

• Pain scores over time

• Range-of-motion measurements

• Strength tests

• Walking distance or tolerance

• Ability to perform daily activities (housework, self-care, driving)

• Work capacity (hours, duties)

• Standardized functional or therapy assessments

Notes on Expected Progress:
[Free-text: provider expectations, milestones, and any red flags to watch for.]

9. Barriers, Risks, and Adjustments

Potential Barriers to Rehabilitation (check and explain if relevant):

• Transportation difficulties

• Cost or insurance limits

• Work schedule conflicts

• Childcare or family responsibilities

• Other health conditions

• Language or communication issues

• Motivation, fear, or psychological factors

• Other: [Describe]

Plan to Address or Reduce These Barriers:
[Free-text: ideas such as scheduling options, telehealth visits, home exercises, support from family or employer, counseling, etc.]

Known Risks or Precautions (as advised by provider):
[Free-text: activities to avoid, signs and symptoms that require urgent care, etc.]

10. Attachments Checklist

Check documents that are attached or available:

• Medical records or visit summaries

• Therapy or rehabilitation evaluation reports

• Work status or restriction notes

• Imaging reports (X-ray, MRI, CT)

• Pain or symptom diary

• Home exercise handouts or diagrams

• Other: [Describe]

11. Acknowledgment and Signatures

Patient / Client Acknowledgment

I, [Patient / Client Full Name], acknowledge that this Rehabilitation Plan is based on the information available at the time of completion and is intended to summarize my recovery goals and treatment steps. I understand that my healthcare providers may modify this plan as my condition changes.

I understand that this document does not replace medical advice, and I should always follow the instructions of my licensed healthcare providers.

Signature (Patient / Client): _______________________________
Printed Name: [Patient / Client Full Name]
Date Signed: [MM/DD/YYYY]

Provider or Therapist (Optional)

I, [Provider / Therapist Name], have reviewed this Rehabilitation Plan with the patient/client and agree that it is consistent with the current treatment recommendations, subject to change as clinically indicated.

Signature (Provider / Therapist): ___________________________
Printed Name: [Name]
Title / Credentials: [MD / DO / PT / OT / DC / NP / PA / Other]
Facility: [Facility Name]
Date Signed: [MM/DD/YYYY]