PATIENT NAME___________________________

PATIENT ID # ____________________________

ASSESSMENT FORM

Name: Sex: M F DOB:

Address: Phone No.:
Therapist: Agency:
Wheelchair being considered: Manual Elec. Assessment Date:

People consulted:

MEDICAL HISTORY

Diagnosis/Onset:
Stable Detoriating

Past Surgeries: Bone Skin Muscle Other

Orthotics/Prosthetics:
Medications:

Medical Doctor: Ph:

Health Professional(s): Ph:

SOCIAL HISTORY

Lives alone Spouse Other Family Friend Other

Primary Carer details: (eg general health, agency contact)
Accomodation: Home/Unit Retirement Village Condo Other
Ownership: Owner Rents Other
Primary Living/Work Environment : (note accessibility, etc.)

Narrowest Doorway: Type of setting: Rural Suburban Urban

Sidewalks Paved Roads Rough Terrain

Other locations where w/c will be used:

Intends to use at night: Yes No

Transportation : Car (passenger) Car (driver) Van Bus Taxi Other

Details:

FUNCTIONAL STATUS

Transfers: Hoist Standing pivot Non-standing pivot Pull to stand Push to stand Sliding
Other: Details/Assistance:
Observed: Yes No

Ambulation status: (note device used)

Wheelchair Use: Independent Assisted Dependent Hours/Day:
 PATIENT NAME___________________________
PATIENT ID # ____________________________
FUNCTIONAL STATUS (continued)
Eating/Meal Preparation:
Communication: (writing/telephone/computer)
Dressing/Grooming:
Bed Mobility: Bed hgt:
Toiletting: Bladder: Continent Odd accident Incontinent Catheterised Intermittent catheter
Bowel: Continent Odd accident Incontinent
Equipment:

Transfers: Seat hgt:

Comments:
Other Daily Activities, eg sport:

PHYSICAL EVALUATION
Visual Hx/Aids :

Visual Scanning/Acuity/Fields : Intact Impaired Comments:

Hearing : Normal Impaired Deaf

Communication : Verbal Non-verbal Method:

Cognition & Perception :

Respiration : Normal Vent. dependent 02 dependent Hx of chronic congestions

Equipment: (eg ventilator, battery, O2 cylinder, suction machine)

Dimensions: Weight:

Sensation : (note areas that are abnormal or insensate)

Skin Integrity : Intact Hx of Sores Red Area Open Area Scar Tissue
at risk from: Orthotics Prolonged Sitting Poor Skin Condition Moisture Other
Comments:

Skin Inspection: Independent Assisted Dependent

Method:

Pressure Relief: Independent Assisted Dependent

Method:

Upper Limb Function: (note coordination & strength )

R handed L handed

Lower Limb Function: (note amputation etc. )

 PATIENT NAME___________________________
PATIENT ID # ____________________________

CURRENT SEATED POSITION (as best evaluated – note fixed positions)

Balance/Trunk Control:

Head: Neutral Hyperextended Fwd flexed Laterally flexed: R L Rotated: R L

L
Shoulders: Level Elevated: R L Sublaxed: R L

Rib Cage: Neutral Elevated: R L Rotated fwd: R L

Spine: Neutral Scoliosis, apex on : R L Kyphosis:

Normal lumbar space Flat Lumbar Space Hyper-lordotic

Pelvis: Neutral Posterior Tilt Anterior Tilt Rotated fwd: R L

Oblique, lower: R L Other:

Hips: Flexed: R L Extended: R L Abducted: R L Adducted: R L

Knees: Flexed (beyond 90º): R L Extended (beyond 90º): R L

Feet: Dorsiflexed: R L Plantarflexed: R L Supinate/Inv: R L

Pronate/Evert: R L Other:

Spasticity/ Reflexes/Tone:

Comments:

WHEELCHAIR HISTORY

1. Manual Elec. Model: Period of use:

Frame Folding Rigid Armrest Hgt: Hanger length:

Seat Depth: Width: Hgt (front): Hgt (back):

Other measurements:
Accessories/Features:

Issues:
Hx of accidents/collisions:

2. Manual Elec. Model: Period of use:

Frame Folding Rigid Armrest Hgt: Hanger length:

Seat Depth: Width: Hgt (front): Hgt (back):

Other measurements:
Accessories/Features:

Issues:
Hx of accidents/collisions:
 PATIENT NAME___________________________
PATIENT ID # ____________________________
BASIC DIMENSIONS

A Seat to elbow:

B Back of knee to heel:

Posterior of buttocks
C
to back of knee:
Widest point at hips or
D
thighs:

E Seat to base of scapula:

Height: Weight:

CLIENT GOALS & CONCERNS

ADDITIONAL NOTES / SUMMARY

Short Term Plan (s ): Mat Evaluation Date/Place:

Trial Equipment :
Date/Place:

Obtain Medical Clearance from Doctor

Obtain further info.
Other:

Therapist’s Signature: Date:

Therapist’s Name: __________________________________________
 WHEELCHAIR SPECIFICATION
Client’s Name: Sex: M F DOB:
Wheelchair Brand:

Frame: Seat Length: Seat Width:

Armrest Cushion
Height: Height: Total
Rear Wheels: Hanger W/chair
Backrest
Length: Width:
Height:

Front Wheels:

Front
Brakes: Back Seat
Seat Height:
Height:

Axles/Axle Plate:

Seat to
Castor to castor: footplate:
Push Handles:
Frame length:

Armrests: Upholstery/Seating :

Footplates/Legrests: :

Options: Headrest Anti-tip bar & roller Tilting bars

Carry bag Oxygen bottle carrier Tray

Stump support IV pole Straps/belts

Clothes Guards Tilt in space: manual / electric Recline: manual / electric
Others:

Details:

ADDITIONAL NOTES:

Therapist’s Signature: Date:

Therapist’s Name: ___________________________________________