Subjective Progress Report
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1
2SUBJECTIVE PROGRESS REPORT
Name ___________________________________________________________ Date _____________________
1. Do you have any questions regarding your care? Yes___ No___ Comments _________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
2. What body signals have improved since your last exam? And how has this impacted your life? _____________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. What body signals remain? And what areas are still limited? ________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4. Please rate your progress so far:
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Very Poor
Excellent
5. Daily Activities: Effects of Current Condition on Performance:
o
o
o
o
Carrying Groceries
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Changing Positions
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Sit or Stand
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Climbing Stairs
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Pet Care
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Driving
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Extended Computer Use
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Household Chores
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Lifting Children
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Reading/Concentration
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Self Care - Bathing
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Self Care - Dressing
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Self Care - Shaving
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Sexual Activities
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Sleep
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Sitting Still
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Standing Still
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Yard Work
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
o
o
o
o
Walking
No Effect
Painful (can do)
Painful (limits)
Unable to Perform
Please list any effects that this may have on any Recreational Activities:_________________________________
__________________________________________________________________________________________
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