Rehabilitation Questionnaire

Click here to download or print this rehabilitation questionnaire (PDF 200k).  Adobe Acrobat is required to print the questionnaire.  Download it for free here.

Rehabilitation is a medical specialty that helps restore good health and function after
an injury or illness. Therapies are designed to renew and retrain your body to overcome physical and mental limitations.

1. Are you experiencing any new pain that has become more severe within the last three months?

2. Is this pain affecting the daily activities in your life?

3. Are you taking more anti-inflammatory or pain medications to reduce your pain?

4. Are you having problems with your balance?

5. Are you becoming tired easily or more than usual?

6. Does it seem that you have lost some strength within the last three months?

7. Are you having trouble putting on clothes, getting out of bed, reaching for a sock, or bathing?

8. Are you noticing stiffness in certain joints?

9. Are you using an assistive device (walker, cane, quad cane, etc.)

10. Are you having problems with comprehending and/or expressing your thoughts?

11. Are you having trouble finding the right words during conversation?

12. Do you have trouble swallowing or choke easily?

13. Are you noticing a difference in your tolerance for activity?

14. Have you been avoiding social activity, or feel anti-social due to your health?

15. Have you experienced any recent weight loss?

If you answered “yes” to any of these questions, you may want to consider using
Peabody’s Rehabilitation Services to help you restore your independence and prevent
painful injuries. Contact us today for more information.