| | Data category | Main content |
| | Patient identification | Name, ID number, gender, date of birth, home address, etc. | | General health | Nutritional status, excretion method, bowel function, sleep mode, safety issues, mental status, language, hearing, vision, activity status, self-care status, etc. | | Past medical history | History of disease, infectious disease, allergy, vaccination, surgery, trauma, blood transfusion, etc. | | History of present illness | The cause, main symptoms, duration, degree of impact of the dysfunction, the status of receiving rehabilitation treatment, etc. | | Professional and psychosocial history | Occupation, lifestyle, economic status, history of marriage and childbirth, family status, living environment, mental state, interests and hobbies, etc. | | Physical examination | Body temperature, pulse, blood pressure, respiration, weight, urinalysis, skin damage, etc. | | Specialist examination | Nervous system and musculoskeletal system examination and measurement, such as advanced brain function, neural reflex, gait analysis, joint range of motion, muscle tone, hand muscle strength, balance disorder, and upper and lower limb function | | Functional rating scale | Activity of Daily Living Scale (ADL), NIH Stroke Scale (NIHSS), European Stroke Scale (ESS), Brunnstorm Motor Function Rating, Fugl-Meyer Assessment (FMA), wolf motor function test (WMFT), manual muscle testing (MMT), range of motion (ROM), Modified Rankin Scale (MRS), Modified Ashworth Scale (MAS), Berg Balance Test, Function Independent Measure (FIM), Modified Barthel Index (MBI), etc. | | Laboratory and instrument examination | Center of gravity measurement, stability limit evaluation, smart Equitest balance master, imaging examination, etc. | | Diagnosis | Disease diagnosis, dysfunction diagnosis, complications, etc. | | Treatment plan | Preliminary rehabilitation goal, rehabilitation method (such as physical therapy, occupational therapy, speech therapy, etc.), types of medications, prevention of systemic risks in rehabilitation medicine, etc. | | Rehabilitation assessment | Short-term and long-term goals of rehabilitation treatment, current treatment plan, treatment points, and precautions |
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