Medical Assessment Form

PLEASE NOTE:
Documents required for admission eligibility assessment:

  1. Recent Chest X-Ray Report
  2. Completed Barthel Index Form [downloadable from our website]
  3. Recent medical documents (e.g. discharge summary/ in-patient summary from hospital, or recent report from your General Practitioner)
  4. List of your current medications (if applicable)
General Information
Medical Background
Functional Assessment
Specialist Referrals
Assessment Summary
Signature and Certification

I hereby certify that this assessment is accurate and based on my professional evaluation.

Assessor's Signature