Rehabilitation Tracking Log Template: Progress & Recovery Notes

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]

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.]

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:

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]

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]

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]

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

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.”]

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

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]

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]