Rehabilitation Tracking Log 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 Reference 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 injury or medical condition: [Describe]
Date of Injury / Surgery: [MM/DD/YYYY]
Insurance Company (if applicable): [Name]
Policy / Claim Number: [Number]
Attorney / Law Firm (if applicable): [Name]
File / Case Number: [Number]
2. Summary of Injury and Treatment Plan
Injury / Diagnosis Summary (brief):
[Example: “Lumbar strain after rear-end collision,” “Post-operative ACL reconstruction – left knee,” etc.]
Body Part(s) Affected:
[Example: neck, lower back, right shoulder, left knee, etc.]
Main Providers Involved in Rehabilitation:
Primary Treating Provider: [Name, Specialty]
Therapy Provider(s): [Name(s), Type: PT/OT/Chiropractic/etc.]
Planned Treatment (short overview):
[Example: “Physical therapy 2x/week for 8 weeks, home exercise program daily, follow-up with orthopedist in 6 weeks.”]
3. Tracking Period
This Rehabilitation Tracking Log covers:
From: [MM/DD/YYYY]
To: [MM/DD/YYYY]
4. Daily Rehabilitation Entry (Repeat for Each Day)
Use one block per day. Copy or extend this section as needed.
Date: [MM/DD/YYYY]
Day of Week: [Mon / Tue / Wed / Thu / Fri / Sat / Sun]
4.1 Symptoms and Pain Levels
Body Part(s) Affected Today:
[Example: “Neck and lower back,” “Right shoulder,” etc.]
Pain Level on Waking (0–10): [0–10]
Highest Pain Level During the Day (0–10): [0–10]
Pain Level at Bedtime (0–10): [0–10]
Describe Pain and Symptoms (brief, in your own words):
[Example: “Sharp pain when bending, dull ache while sitting, tingling in right hand,” etc.]
4.2 Treatment and Therapy Received Today
Was there any professional treatment today?
No
Yes – check and describe:
Professional Treatments:
Physical therapy (PT) – [Clinic Name / Focus of today’s session]
Occupational therapy (OT) – [Details]
Chiropractic visit – [Details]
Doctor / specialist visit – [Provider and purpose]
Counseling / psychological support – [Topic/brief note]
Other treatment – [Describe]
Time of Appointment(s): [HH:MM a.m./p.m., list if multiple]
Key Activities or Notes from Today’s Session(s):
[Example: “Worked on core stabilization and hip strengthening,” “Manual therapy to lower back,” “Reviewed ergonomic changes for work.”]
4.3 Home Exercises and Self-Care
Home Exercises Completed Today (check and describe):
Stretching – [Type, sets/reps or minutes]
Strengthening exercises – [Type, sets/reps]
Balance / coordination work – [Description]
Walking or cardio activity – [Distance or time]
Other prescribed exercises – [Describe]
Did you follow any specific self-care instructions?
Ice or cold pack – [Area and duration]
Heat – [Area and duration]
Rest / activity modification – [Describe]
Use of brace, sling, cane, or other device – [Describe]
Other self-care – [Describe]
4.4 Medication Taken (If Relevant)
List medications related to this injury taken today (if any):
Medication 1: [Name and dose] – Times Taken: [e.g., 8:00 a.m., 8:00 p.m.]
Medication 2: [Name and dose] – Times Taken: [Times]
Medication 3: [Name and dose] – Times Taken: [Times]
Side Effects or Issues Noticed:
[Example: “Drowsy after afternoon dose,” “Mild nausea,” or “No side effects noted.”]
4.5 Functional Abilities and Limitations
Work / School Status Today:
Did not work / attend school due to injury
Worked / attended school with restrictions
Worked / attended school full duty
Not employed / not in school
If you worked or attended school, briefly describe any difficulties:
[Example: “Could not sit longer than 30 minutes without pain,” “Needed help lifting items over 10 lbs,” etc.]
Daily Activities Affected Today (check and describe briefly):
Walking or standing – [Description]
Sitting – [Description]
Household tasks (cleaning, cooking, laundry) – [Description]
Driving or transportation – [Description]
Caring for children or family – [Description]
Hobbies or exercise – [Description]
Sleep – [Description, e.g., “Woke up 3 times from pain.”]
4.6 Overall Daily Summary
Overall, compared to yesterday, today was:
Better
About the same
Worse
Brief Daily Summary (in your own words):
[Example: “Pain slightly improved, tolerated PT session well,” “Back worse after long car ride,” “More sore today after new exercises.”]
5. Weekly or Period Summary (Optional)
Use this section at the end of each week or tracking period.
Week / Period Covered: [e.g., “Week of 05/01/2025–05/07/2025”]
Average Pain Level This Week (0–10): [0–10]
Biggest Improvements:
[Short bullet list, e.g., “Can walk 20 minutes,” “Better sleep,” “Less stiffness in the morning.”]
Biggest Challenges:
[Short bullet list, e.g., “Still can’t sit more than 30 minutes,” “Strong pain after PT,” etc.]
Changes in Treatment or Medications:
[Describe any new exercises, added or stopped medications, or changes in visit frequency.]
Questions or Issues to Discuss at Next Appointment:
[Free-text list]
6. Attachments Checklist
Check any items you are keeping with this log:
Therapy or home exercise instructions
Doctor’s visit summaries
Updated work status or restriction notes
Pain or symptom charts or graphs
Copies of appointment schedules or reminders
Other related documents: [Describe]
7. Certification (Optional)
I, [Patient / Client Full Name], certify that the entries in this Rehabilitation Tracking Log are truthful and based on my own experiences during the period covered. I understand that this log may be shared with my healthcare providers, insurer, or attorney to help evaluate my recovery and needs.
Signature: _______________________________
Printed Name: [Patient / Client Full Name]
Date Signed: [MM/DD/YYYY]
Place Signed (City, State/Province): [Location]
