Patient Follow Up Survey

Please check the most appropriate amount of change in your functional level from the time you were discharged from therapy to now that three months have past as related to the following areas. If the specific area does not apply to an area that you were treated for, please check off the "Never" box when available:

1. Overall functional level:
   

   More functional Improved

   Unchanged Same

   Less functional Worse

   
   
2. Pain, overall endurance, range of motion, and strength:
   

   More functional Improved

   Unchanged Same

   Less functional Worse

   Never had been a problem/goal

   
   
   
3. Emotional/psychological well being/adjustment:
   

   More functional Improved

   Unchanged Same

   Less functional Worse

   Never had been a problem/goal

   
   
   
4. Cognitive abilities/memory/problem solving:
   

   More functional Improved

   Unchanged Same

   Less functional Worse

   Never had been a problem/goal

   
   
   
5. Communication skills:
   

   More functional Improved

   Unchanged Same

   Less functional Worse

   Never had been a problem/goal

   
   
   
6. Ability to care for your self/activities of daily living:
   

   More functional Improved

   Unchanged Same

   Less functional Worse

   Never had been a problem/goal

   
   
   
7. Mobility/ability to move within your environment:
   

   More functional Improved

   Unchanged Same

   Less functional Worse

   Never had been a problem/goal

   
   
   
8. Ability to complete home management, go into the community, and complete leisure activities:
   

   More functional Improved

   Unchanged Same

   Less functional Worse

   Never had been a problem/goal

   
   
   
9. Vocational/work status:
   

   More functional Improved

   Unchanged Same

   Less functional Worse

   Never had been a problem/goal

   
   
   
10. Living arrangement:
    

    Same as when I was discharged

    Now my living arrangement provides me with more care

    Now my living arrangement provides me with less care

    
    
    
11. Patient satisfaction:
    
    If you were to need rehabilitative services again or if you were asked to recommend a rehabilitation facility, would you choose Schuylkill Rehab Center?
    

    YES, I would return or recommend

    NO, I would not return or recommend

    
    
    
12. Comments:
    
    Since your discharge from Schuylkill Rehab, has your functional level been significantly decreased due to medical complications or other conditions?
    

    YES, new medical conditions have occurred

    NO, no new medical conditions have occurred since my discharge