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Run: Cancer Rehabilitation Evaluation

Cancer Rehabilitation Evaluation template for documenting treatment history, fatigue, functional limits, precautions, and rehab goals before oncology therapy...

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Evaluation Details

Evaluation date (required)

Referring provider

Enter the clinician or service that referred the patient for oncology rehabilitation.

Care setting (required)

Primary rehabilitation discipline (required)

Current cancer treatment status (required)

Cancer and Treatment History

Cancer type or primary site (required)

Examples: breast, lung, colorectal, lymphoma. Avoid collecting more detail than needed for therapy planning.

Current or recent treatments (required)

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 (required)

Pain severity

Mobility limitations (required)

Activities affected by symptoms (required)

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 (required)

Precautions or restrictions

Objective notes

Document measurable findings, screening results, or clinically relevant observations.

Goals, Consent, and Submission

Patient-stated goals (required)

Describe the activities or outcomes the patient wants to improve through rehabilitation.

Primary therapy priorities (required)

Consent to collect and use clinical information (required)

I understand this form collects health information needed for rehabilitation planning and care coordination.

Yes No N/A

Submission acknowledgement

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Email (required)

Your name (optional)

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