Mobility Evaluation Form PDF Details

Embarking on the journey of obtaining or upgrading mobility aids involves a comprehensive process that begins with filling out the Mobility Evaluation form. This form is a detailed document that captures a wide range of essential information, starting with the basic patient information such as name, date of birth, address, and extending to intricate details concerning the patient's medical history, diagnosis codes, and information about the patient's current seating and mobility arrangements. Importantly, it dives into the patient's goals, caregiver’s expectations, and specific limitations that may influence care, thereby setting the stage for a tailored approach to mobility solutions. Moreover, the form evaluates the patient's home and community environment, their transportation needs, and their daily living activities, to ensure that any equipment recommended will enhance their quality of life. The patient’s functional and sensory processing skills are assessed to identify any areas that might affect the safe operation of a wheelchair. The evaluation also looks into the patient's communication abilities, sensation and skin integrity issues, and their current seating and mobility systems to determine the necessity for adjustments or new equipment. The form's comprehensive nature requires input from various professionals, including physicians, therapists, and equipment suppliers, underscoring the multidisciplinary approach needed for effective mobility aid provision. Thus, the Mobility Evaluation form serves as a crucial tool in mapping out an individual's specific needs and preferences, paving the way for enhanced mobility and independence.

QuestionAnswer
Form NameMobility Evaluation Form
Form Length12 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min
Other namesmobility evaluation form pdf, mobility evaluation form sample, seating justification make, durable medical equipment mobility evaluation form

Form Preview Example

Seating/Mobility Evaluation

PATIENT INFORMATION:

Name:

 

 

 

Date seen:

 

 

 

DOB:

Sex:

 

Address:

 

 

 

Physician:

 

 

 

Phone:

 

 

 

 

 

 

 

Seating Therapist:

 

 

 

Phone:

 

 

Phone:

 

 

 

Primary Therapist:

 

 

 

Phone:

 

 

Referred by: (If other than MD)

 

Equipment Supplier Company:

 

Caregiver name:

 

 

Insurance/Payor:

 

 

Contact person:

 

 

 

 

 

 

Recipient#:

 

 

 

Phone:

 

 

 

Phone number:

 

 

Reason for

 

 

 

 

 

 

 

 

 

 

 

Referral

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Goals:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Caregiver goals

 

 

 

 

 

 

 

 

 

 

 

and specific

 

 

 

 

 

 

 

 

 

 

 

limitations that

 

 

 

 

 

 

 

 

 

 

 

may effect care:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL HISTORY:

 

 

 

 

 

 

 

 

 

 

Diagnosis:

ICD9

Diagnosis:

 

 

 

ICD9

Diagnosis:

 

 

 

 

Code:

 

 

 

 

 

Code:

 

 

 

 

 

 

ICD9

Diagnosis:

 

 

 

ICD9

Diagnosis:

 

 

 

 

Code:

 

 

 

 

 

Code:

 

 

 

 

 

 

ICD9

Diagnosis:

 

 

 

ICD9

Diagnosis:

 

 

 

 

Code:

 

 

 

 

 

Code:

 

 

 

 

Progressive Disease

Osteoporosis

 

 

Recent/future surgeries/prognosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Height:

 

Weight:

 

 

Explain recent changes or trends in weight:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

History:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardio Status:

 

Functional Limitations:

 

 

 

 

 

 

Intact Impaired

 

 

 

 

 

 

 

 

 

 

Respiratory Status:

Functional Limitations:

 

 

 

 

 

 

Intact Impaired

 

 

 

 

 

 

 

 

 

 

Orthotics:

 

 

 

 

 

 

 

 

 

 

 

HOME ENVIRONMENT:

 

 

 

 

 

 

 

 

HouseCondo/town home Apartment Asst Living LTCF

own rent

 

 

 

 

Lives Alone Lives with Others

 

Hours without caregiver:

 

 

 

 

 

 

Entrance:

Level Stairs Ramp Lift

 

Width of entrance:

Number of floors:

 

 

Accessible Bedroom Accessible Bathroom

Narrowest Doorway to access:

 

 

 

 

Non-accessible rooms:

 

 

 

 

 

 

 

 

 

 

Storage of Wheelchair:

 

 

 

 

 

 

 

 

 

 

 

Name:

MR#:

 

Insurance/Recipient#

 

COMMUNITY ADL:

 

 

 

 

TRANSPORTATION: Car Van

Bus Adapted w/c Lift

Ambulance

Other:

 

Where is w/c stored during transport?

Size of area needed for transport of w/c w x d x h:

 

Self Driver Drive while in Wheelchair yes no

Tie Downs:

 

 

Van head clearance: Door _____”

Inside _____”

Van door width ______” Ramp lift w ____” x d _____”

#Hours per day/specific requirements pertaining to mobility

Employment:

#Hours per day/specific requirements pertaining to mobility

School:

Other

FUNCTIONAL/SENSORY PROCESSING SKILLS:

Handedness: Right Left Comments:

Functional Processing Skills for Wheeled Mobility

Processing Skills are adequate for safe wheelchair operation

Areas of concern that may interfere Description or problem/Plan to ensure safety with safe operation of wheelchair

Attention to environment

Judgment

Vision or visual processing

Hearing

Motor Planning

Fluctuations in Behavior

COMMUNICATION:

Verbal Communication WNL Understandable Difficult to understand non-communicative Uses an augmentative communication device Manufacturer/Model :

Equipment needs/ Mounting:

SENSATION and SKIN ISSUES:

Sensation

Sensory Tactile Processing

Hyposensate Hypersensate Defensiveness

Intact

ImpairedComplaint of Pain: Please describe

Absent

Level of sensation:

Skin Issues/Skin Integrity

Current Skin Issues Yes No

History of Skin Issues Yes No

Hx of skin flap surgeries Yes No

Intact Red areaOpen Area

Where ________________________

Where ________________________

Scar Tissue At risk from prolonged sitting

When _________________________

When _________________________

Where ___________________________

 

 

Comments:

 

 

ADL STATUS (in reference to wheelchair use):

Indep Assist

Unable

Indep

Not

Comments

 

 

with

assessed

 

 

 

Equip

 

 

Dressing

 

 

 

 

 

 

 

 

 

Eating

 

 

 

Describe oral motor skills

 

 

 

 

 

Grooming/Hygiene

 

 

 

 

Meal Prep

 

 

 

 

 

IADLS

 

 

 

 

 

Bowel Mngmnt: Continent

Incontinent Accidents

Comments:

 

Bladder Mngmt: Continent

Incontinent Catheter

Comments:

 

Equipment eval/justification form

2/12

Name:

MR#:

Insurance/Recipient#

CURRENT SEATING / MOBILITY:

 

 

Current Mobility Base: None Dependent Dependent with Tilt Manual Scooter Power Type of Control:

Manufacturer:

Model:

Serial #:

Size:

Color:

Age:

 

 

Current Condition of Mobility Base:

 

Current Seating System:

 

Age of Seating System:

COMPONENT

MANUFACTURER/CONDITION

 

Seat Base

Cushion

Back

Lateral trunk supports

Thigh support

Knee support

Foot Support

Foot strap

Head Support

Pelvic Stabilization

Anterior Chest/Shoulder

Support

UE Support

Other

Describe Posture in present seating system:

WHEELCHAIR SKILLS:

 

 

 

Indep

Assist

Unable

N/A

Comments

 

 

Bed ↔ w/c Chair Transfers

 

 

 

 

w/c ↔ Commode Transfers

 

 

 

Manual w/c Propulsion:

 

One arm: left right

 

 

 

 

 

 

 

 

 

 

 

 

One foot:leftright Both Feet

 

 

 

 

 

 

 

Safe

Functional

Distance:

Operate Scooter

 









Safe

Functional

Distance:

 

 

 

Operate Power w/c: Std. Joystick

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Operate Power w/c: w/ Alternative

 

 

 

 

 

 

 

 

 

 

 

 

Controls

 

 

 

 

 

 

 

 

Able to perform Weight Shifts/Pressure

Method:

 

 

Relief

 

 

 

 

 

 

 

 

 

 

 

Bed Confined without

Yes

No

 

Hours spent sitting in w/c each day:

 

 

w/c

 

 

 

 

 

 

 

 

 

Does Mobility Meet Functional Requirement? Yes No

Activity Tolerance/Endurance:

Additional Comments:

Equipment eval/justification form

3/12

Name:

 

MR#:

Insurance/Recipient#

MOBILITY/BALANCE:

 

 

 

 

Balance

 

 

Transfers

Ambulation

Sitting Balance:

Standing Balance

 

Independent

Unable to Ambulate

WFL Uses UE for

WFL

 

Min Assist

Ambulates with Asst

support

 

 

 

 

Min Support

Min Support

 

Max Asst

Ambulates with Device

Mod Support

Mod Support

 

Sliding Board

Independent without Device

Unable

Unable

 

Lift / Sling Required

Indep. Short Distance Only

Comments:

MAT EVALUATION:

 

 

A

F

 

B

 

 

G

C

 

H

 

 

 

I

 

D

 

 

J

 

 

K

L

 

 

M

E

 

 

N

 

 

O

 

 

Measurements in Sitting:

Left

Right

 

 

A: Shoulder Width

 

 

 

Seat to Axilla

 

B: Chest Width

 

 

H: Seat to Top of Shoulder

 

C:

Chest Depth (Front – Back)

 

 

I:

Acromium Process (Tip of Shoulder)

 

D:

Hip Width

 

 

J:

Inferior Angle of Scapula

 

**

Asymmetrical Width for windswept legs

 

 

K:

Seat to Elbow

 

D:

Hip Width

 

 

L:

Seat to Iliac Crest

 

E:

Between Knees

 

 

M:

Upper leg length

 

F:

Top of Head

 

 

N:

Lower leg length

 

G:

Occiput

 

 

O:

Foot Length

Additional Comments:

**Asymmetrical Width: i.e., windswept or Scoliotic posture; widest point to widest point

DESCRIBE REFLEXES/TONAL INFLUENCE ON BODY:

Equipment eval/justification form

4/12

Name:

 

 

 

 

 

MR#:

 

Insurance/Recipient#

 

 

 

 

 

 

 

 

 

 

 

POSTURE/TONE:

 

FUNCTION:

 

COMMENTS:

 

SUPPORT NEEDED

HEAD

Functional

 

 

 

Good Head Control

 

Describe Tone/Movement

 

 

 

 

 

 

 

 

 

 

 

of head and Neck:

 

 

&

Flexed

Extended

Adequate Head Control

 

 

 

NECK

Rotated L

Lat Flexed L

Limited Head Control

 

 

 

 

 

 

Rotated R

Lat Flexed R

 

 

 

 

 

 

 

 

Cervical Hyperextension

Absent Head Control

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SHOULDERS

R.O.M.

 

 

Describe

 

 

 

 

 

 

 

 

 

WNL

 

 

Tone/Movement of UE:

 

 

 

 

 

 

 

 

WFL

 

 

 

 

 

 

 

 

 

 

 

 

Limitations:

 

 

 

 

 

E

Left

 

 

 

Right

 

 

 

 

 

 

 

X

Functional

 

Functional

 

 

 

 

 

 

U

T

elev / dep

 

elev / dep

Strength concerns:

 

 

 

P

R

pro-retract

 

pro-retract

 

 

 

 

 

 

P

E

subluxed

 

subluxed

 

 

 

 

 

 

E

M

 

ELBOWS

R.O.M.

 

 

 

 

 

R

I

Left

 

 

 

Right

 

 

 

 

 

 

 

T

 

 

 

 

Strength concerns:

 

 

 

 

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WRIST

Left

 

 

Right

Strength / Dexterity:

 

 

 

 

&

 

 

 

 

 

 

 

 

 

 

 

HAND

Fisting

 

 

 

 

 

 

 

 

 

 

 

Anterior / Posterior

Left Right

 

Rotation-shoulders and

 

 

 

 

 

 

 

 

 

 

 

upper trunk

 

 

 

T

 

 

 

 

 

 

 

 

Neutral

 

 

 

R

 

 

 

 

 

Degree of curvature: _______ o

Left-anterior

 

 

 

U

 

 

 

 

 

 

 

 

Right-anterior

 

 

 

N





 



 





 

 

 

 

K

WFL

↑ Thoracic

 

↑ Lumbar

WFL

Convex

Convex

 

 

 

 

 

 

Kyphosis

Lordosis

 

Left

Right

 

 

 

 

 

 

 

 

 

 

c-curve s-curve multiple

 

 

 

 

 

Fixed

 

Flexible

Fixed

Flexible

Fixed

Flexible

 

 

 

Partly Flexible

Other

Partly Flexible Other

Partly Flexible

Other

 

Equipment eval/justification form

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