Geriatrics
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Checklist for skilled/care rehabilitation needs

Supine to sit:
[radio name="variable_1" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"]

Sit to stand:
[radio name="variable_2" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"]


Ambulation:
[radio name="variable_3" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"]

Feeding:
[radio name="variable_4" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"]

Toilet transfers:
[radio name="variable_5" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"]

Grooming:
[radio name="variable_6" value="Independent|Stand By Assist/Supervision|Assist Minimal (patient performs at least 75 percent of activity)|Assist Moderate (patient performs at least 50 percent of activity)|Assist Maximal (patient performs less than 25 percent of activity)|Dependent"]

Dysphagia:
[radio name="variable_7" value="absent|present"]

Tube feedings:
[radio name="variable_8" value="does not require|REQUIRES"]

IV antibiotics:
[radio name="variable_9" value="does not require|REQUIRES"]
Checklist for skilled/care rehabilitation needs

Supine to sit:


Sit to stand:



Ambulation:


Feeding:


Toilet transfers:


Grooming:


Dysphagia:


Tube feedings:


IV antibiotics:

Result - Copy and paste this output: