Healthcare Progress Survey

HEALTHCARE PROGRESS SURVEY

This Healthcare Progress Survey is a clinical record used to document the patient’s current status, response to treatment, functional abilities, and goals. The information supplied will be used in the patient’s medical chart and for ongoing care coordination. Provide accurate, complete responses to assist in clinical decision-making.

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History & Current Medications

Current Status & Progress

Date of Survey:

Current pain score:

Pain    Fatigue    Shortness of breath    Cognitive changes

Mobility limitation    Appetite change    Other:

Bathing:

Dressing:

Mobility (ambulation/transfers):

Treatment Response and Care Plan

Safety Screening

Recent falls in past 90 days:

Home safety concerns identified:

Suicidal ideation or self-harm risk: Yes No

Privacy, Authorization, and Certification

I acknowledge that the information provided on this survey will be recorded in my medical record. I authorize the use and disclosure of the information in this survey to other healthcare providers and staff involved in my care for purposes of treatment, care coordination, and payment. I understand that protected health information contained in this document may be disclosed to individuals involved in my care unless I instruct otherwise in writing.

I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on: or upon completion of care, whichever occurs first.

Certification: I certify that the information provided on this Healthcare Progress Survey is true and complete to the best of my knowledge. I understand that knowingly providing false information may affect my treatment and may be noted in the clinical record.

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