Home Program & Progress Review

This review is completed by you, the patient, to reflect on how your home program and recovery have gone over this stretch of your care. Your honest answers help your therapist see what is working, adjust your program, and plan the next steps together.

Section 1 — About This Review

Your name:

Review date:

Treating therapist:

Area / condition being treated:

Section 2 — How You Feel Now

Rate each item from 0 to 10, then add a short note if you like.

Section 3 — Your Home Program

How well were you able to keep up with the exercises your therapist gave you?

I did them most days as prescribed

I did some of them, but not consistently

I struggled to fit them in

Roughly how many days per week did you do them?

Which exercises felt helpful, and which felt hard or uncomfortable?

What got in the way of doing your exercises (time, pain, unsure of technique, other)?

Section 4 — Everyday Activities

Which everyday activities are still difficult for you? (select any that apply)

Walking or standing for long

Stairs

Lifting or carrying

Work or study tasks

Sport, hobbies, or exercise

Sleep

Describe one activity you can now do that was hard before, and one you still want to get back to:

Section 5 — Goals & Next Steps

Where would you like to be by your next review? What matters most to you right now?

How do you feel about your progress overall? (select one)

Happy — I am moving in the right direction

Mixed — some progress, some concerns

Concerned — I would like to talk this through

Anything else you would like your therapist to know?

Section 6 — Confirmation

The answers above reflect my honest experience to the best of my knowledge.

I would like my therapist to review and adjust my home program based on this feedback.

Your signature:

Thank you for taking the time to reflect. Your therapist will go through this with you and shape the next stage of your program together.