·Renew ·Restore ·Revitalize

Espanol
line decor
  
line decor
 
 
 
 
 
 
LifeCare Self-Assessment

 

Take this self assessment into your physician. Your physician will determine if a referral to LifeCare of Florida is appropriate.

Circle each activity you are having difficulty with or experiencing a decline with from the following:

Daily Living Tesks

  • Eating
  • Dressing
  • Bathing
  • Moving from bed to chair
  • Moving from chair to standing
  • Speaking or Communicating Clearly
  • Toileting
  • Swallowing

Instruments of Daily Living

  • Telephone
  • Shopping
  • Taking Medications
  • Traveling
  • Housework
  • Preparing Meals
 

  Copyright 2007 © LifeCare of Florida | Legal Notice
 

Fall Risk

  • Fall
  • Walking
  • Near fall or loss of balance
  • Balance
  • Concentration

Disease Impairment
Circle "yes" if you have a chronic disease or impairment that impacts your ability to function independently.

YES

NO

Do you need the assistance of (Circle all that apply):

  • CareGiver
  • Walker
  • Wheelchair
  • Cane

LifeCare of Florida

Providing Outpatient Rehabilitation Therapy Services "In the comfort of your home or in our supportive outpatient therapy office"

Rehabilitation Therapy Services

  • Physical Therapy
  • Occupation Therapy
  • Speech Language Pathology

 

(407) 682-3600