Cancer Rehabilitation Evaluation

Intake and evaluation form to document cancer-related fatigue, functional limitations, treatment-related impairments, and rehabilitation goals to establish a baseline for oncology therapy planning.

Evaluation Details

• Evaluation date
• Referring provider
  Enter the clinician or service that referred the patient for oncology rehabilitation.
• Care setting
• Primary rehabilitation discipline
• Current cancer treatment status

Cancer and Treatment History

• Cancer type or primary site
  Examples: breast, lung, colorectal, lymphoma. Avoid collecting more detail than needed for therapy planning.
• Current or recent treatments
• Treatment end date
• Treatment-related side effects affecting function
• Additional treatment notes
  Include clinically relevant details only, such as precautions, restrictions, or treatment-related impairments.

Symptoms and Functional Impact

• Fatigue severity
• Pain severity
• Mobility limitations
• Activities affected by symptoms
• Functional impact summary
  Briefly describe how symptoms limit participation in daily routines, roles, or independence.

Objective Findings and Precautions

• Performance status
• Range of motion or strength concerns
• Edema or lymphedema present
• Precautions or restrictions
• Objective notes
  Document measurable findings, screening results, or clinically relevant observations.

Goals, Consent, and Submission

• Patient-stated goals
  Describe the activities or outcomes the patient wants to improve through rehabilitation.
• Primary therapy priorities
• Consent to collect and use clinical information
  I understand this form collects health information needed for rehabilitation planning and care coordination.
• Submission acknowledgement