Discharge Report Template by zou21348

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									                                                                              1867 Yonge Street, Suite 901
                                                                                    Toronto, ON M4S 1Y5
                                                                                     Ph: (800) 469 ∙ 2127
                                                                                     Fax: (800) 747∙ 5208
                                                                                  www.justassessments.ca
                                     DISCHARGE REPORT
Patient Name:
DOB:
Address:


Subjective Reports of Progress:




Objective Measurements:




Analysis of Progress:




Recommendations for Further Interventions:




Treatment Goals                                    Status of Goals
1)
2)
3)
4)
5)
6)
Total Number of Treatments:                        Last Treatment Date:


   * ACTIVE Health Management Suggests using the following Objective Measurement Tools
    The Lower Extremity Functional Scale (LEFS)
    The Numeric Pain Rating Scale(NPRS)
    The Neck Disability Index (NDI)
    The Disabilities of the Arm, Shoulder, and Hand (DASH)
    The Health Status Disability Questionnaire (HSDQ)
    The Roland Morris Questionnaire (RMQ)
   Objective Measurement Tools in Children’s Services
    The School Function Assessment (SFA)
    The Pediatric Evaluation of Disability Inventory (PEDI)
    Test of Motor Impairment (TMI)
    Basic Gross Motor Assessment (BGMA)

								
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