Patient Information
Name: _________________________
Date of Stroke: _________________
Primary Neurologist: ____________
Recovery Goals
Short-term Goals (1-3 months)
- Improve mobility and balance
- Enhance daily living activities
- Establish communication strategies
- Manage medication schedule
Long-term Goals (3-12 months)
- Return to independent living
- Resume modified work activities
- Strengthen social connections
- Prevent secondary complications
Rehabilitation Schedule
Physical Therapy
- Frequency: ____ times per week
- Focus areas:
- Muscle strength
- Balance training
- Gait improvement
- Range of motion exercises
Occupational Therapy
- Frequency: ____ times per week
- Focus areas:
- Daily living activities
- Home safety modifications
- Adaptive equipment training
Speech Therapy (if applicable)
- Frequency: ____ times per week
- Focus areas:
- Speech clarity
- Swallowing exercises
- Communication strategies
Medication Management
Current Medications
- ____________________ Dosage: _____ Time: _____
- ____________________ Dosage: _____ Time: _____
- ____________________ Dosage: _____ Time: _____
Risk Factor Management
- Blood pressure target: /
- Blood sugar target: _____
- Cholesterol target: _____
- Weight management goal: _____
Follow-up Appointments
- Neurologist: Every _____ months
- Primary Care: Every _____ months
- Rehabilitation team: Every _____ weeks
Emergency Plan
Call 911 or seek immediate medical attention if experiencing:
- Sudden weakness or numbness
- Speech difficulties
- Severe headache
- Vision problems
- Loss of balance
Support Resources
- Stroke Support Group: ________________
- Social Worker Contact: ______________
- Home Health Agency: ________________
Progress Notes
Date: _________ Comments: _________________
Date: _________ Comments: _________________
_Patient Signature: ________________________
Date: ___________________________________
Physician Signature: ______________________
Date: ___________________________________