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

5/12

Name:

 

 

 

 

 

 

MR#:

 

Insurance/Recipient#

 

 

 

 

 

 

 

 

 

 

POSTURE/TONE:

 

FUNCTION:

 

COMMENTS:

SUPPORT NEEDED

P

Anterior / Posterior

 

 

Obliquity

 

Rotation-Pelvis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V







 

 











 

I

Neutral

Posterior

Anterior

 

WFL

R elev

l elev

WFL

Right

Left

 

S

 

 

 

 

 

 

 

 

 

 

Anterior Anterior

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fixed

Other

 

Fixed

Other

Fixed

 

Other

 

 

Partly Flexible

 

 

 

 

Partly Flexible

 

Partly Flexible

 

 

Flexible

 

 

 

 

 

Flexible

 

 

Flexible

 

 

 

 

 

Position

 

Windswept

 

Range

 

 

 

 

 

 

 

 

 

 

 

 

 

of

 

 

 

H

 

 

 

 

 

 

 

 

 

Motion

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P





  





 

 

 

 

S

Neutral

ABduct

 

ADduct

 

Neutral

Right

Left

 

Left

Right

 

 

 

 

 

 

 

 

 

 

 

WNL

 

 

 

 

 

 

 

 

 

 

 

 

 

Adequate

 

 

 

 

 

 

 

 

 

 

 

 

 

for sitting

 

 

 

 

Fixed

Subluxed

 

Fixed

Other

 

 

 

 

 

Partly Flexible

Dislocated

 

Partly Flexible

 

Limitations

 

 

 

 

Flexible

 

 

 

 

 

Flexible

 

 

 

 

 

 

 

Knee

R.O.M.

 

Strength concerns:

 

Foot Positioning

Foot Positioning Needs:

 

Left

 

 

Right

 

 

 

 

WFL

 

L R

 

KNEES

WFL

 

WFL

 

 

 

 

ROM concerns:

 

 

&

Limitations

Limitations

 

Knee/Hamstring positioning

Dorsi-Flexed

 

L R

 

 

needs:

 

 

 

 

 

 

 

 

 

 

 

 

FEET

 

 

 

 

 

 

 

 

 

Plantar Flexed

L R

 

 

 

 

 

 

 

 

 

Inversion

 

L R

 

 

 

 

 

 

 

 

 

 

 

Eversion

 

L R

 

Goals for Mobility Base

Goals for Seating system

Simulation Ideas/Equipment trials/ State why other equipment was unsuccessful:

Equipment eval/justification form

6/12

Name:

 

MR#:

Insurance/Recipient#

MOBILITY BASE RECOMMENDATIONS and JUSTIFICATION

 

 

MOBILITY BASE

JUSTIFICATION

General Info

 

See specifics below

 

 

Dependent Manual Power

 

 

 

Scooter

R L

 

 

 

Power Control

 

 

 

Other:

Color:

 

 

 

 

 

provide transport from point A to B

Manufacturer:

 

promote Indep mobility

 

 

Model:

 

is not a safe, functional ambulatory

 

Size: Width

 

 

 

 

 

Seat Depth

 

 

 

 

 

 

 

Back Height

 

 

 

 

Seat to Back Height

 

 

 

Stroller Base

 

infant child

 

non-functional ambulatory

 

 

unable to propel manual wheelchair



 

 

allows for growth

 

 

Manual Mobility Base

non-functional ambulator

 

K0004 K0005 K0006 E1235

 

 

E1236 E1237 E1238

 

 

 

 

 

 

 

 

Push handles

 

caregiver access

 

allows “hooking” to enable

extended angle adjustable

caregiver assist

 

increased ability to perform ADLs or

standard

 

 

 

maintain balance

Lighter weight required

self propulsion

 



 

 

lifting

 

 

Heavy Duty required

user weight greater than 250

 

broken frame on previous chair

 

 

pounds

 

multiple seat functions

 

 

extreme tone

 



 

 

over active

 

 

Specific seat height required

foot propulsion

 

access to table or desk top

Floor to seat height

 

transfers

 



 

 

 

 

 

accommodation of leg length

 

 

Rear wheel placement/Axle

improved UE access to wheels

 

stability

adjustability

 

improved stability

 

1-arm drive access

None semi adjustable fully

changing angle in space for

 

amputee placement

adjustable

 

improvement with postural

 



Angle Adjustable Back

postural control

 

UE functional control

 

 

control of tone/spasticity

 

accommodation for seating system

 

 

accommodation of range of motion



Tilt Base or added

change position against

 

management of tone

Forward Backward

gravitational force on head and

 

rest periods

 

 

shoulders

 

control edema

E1161 E1231 E1232 E1233

change position for pressure

 

facilitate postural control

E1234

 

relief/can not weight shift

 



 

transfers

 

 

 

 

 

 

 

 

 

 

Equipment eval/justification form

7/12

Name:

 

MR#:

Insurance/Recipient#

 

 

 

MOBILITY BASE

JUSTIFICATION

Recline Base

accommodate femur to back angle

rest periods

E1125 E1126

bring to full recline for ADL care

 

repositioning for transfers or

 

 

change position for pressure

 

clothing/diaper /catheter changes

 

 

relief/can not weight shift

 



 

 

head positioning

 

 

Elevator on Mobility Base

increase Indep in transfers

 

raise height for communication at

 

 

increase Indep in ADLs

 

standing level

 

 

 

 



 

 

 

 

Scooter/POV

can safely operate

 

has adequate trunk stability

E1230

 

can safely transfer

 

can not propel manual wheelchair

 

 

 

 



Power Mobility Base

non-ambulatory

 



K0010 K0011 K0012 K0014

can not propel manual wheelchair

 

 

E1239

 

 

 

 

W/C controls

provides access for controlling

 

computer access

Body Part _______________

wheelchair

 

power tilt or recline

Proportional

safety

 

programming for accurate control

Non-Proportional/switches

EADL access

 



Electronic Mechanical

 

 

 

Manufacturer/Model:

 

 

 

E2320 E2321 E2322 E2323

 

 

 

E2324 E2325 E23226 E2327

 

 

 

E2328 E2329 E2330 E2331

 

 

 

E2399

 

 

 

 

 

 

 

 

Hangers/ Leg rests

provide LE support

 

durability

70 90 elevating articulating

accommodate to hamstring

 

enable transfers

fixed lift off swing away

tightness

 

decrease edema

rotational hanger brackets

elevate legs during recline

 



adjustable knee angle recessed calf

provide change in position for Les

 

 

panel heavy duty Other

 

 

 

E0990 K0195 K0053

 

 

 

 

 

 

 

Foot support

Support foot

 

transfers

adjustable Footplate R L

accommodate to ankle ROM

 



flip up

depth adjustable

allow foot to go under wheelchair

 

 

K0040 K0041

base

 

 

 

 

 

 

 

Armrests

 

provide support with elbow at 90

 

remove for transfers

fixed adjustable height removable

provide support for w/c tray

 

allow to come closer to table top

swing away

change of height/angles for variable

remove for access to tables

flip back

reclining

activities

 

full length pads desk pads tubular

 

 

K0106 K0020 E0873

 

 

 

 

 

 

 

 

Equipment eval/justification form

8/12

Name:

MR#:

Insurance/Recipient#

 

 

 

MOBILITY BASE

JUSTIFICATION

Wheel size:

increase access to wheel

 

increase propulsion ability

Style

allow for seating system to fit on

 

maintenance

mag spokes

base

 



Quick Release Wheels

allows wheels to be removed to

 

decrease weight for lifting

 

decrease width of w/c for storage

 



Wheel rims/ hand rims

provide ability to propel manual

 



E0967

wheelchair for individual with hand

 

 

metal plastic coated vertical

weakness/decreased grasp

 

 

projections oblique projections

 

 

 

Tires: pneumatic flat free inserts

decrease maintenance

 

decrease pain from road shock

solid

prevent frequent flats

 

decrease spasms from road shock

K0093 K0097

increase shock absorbency

 



Caster housing:

maneuverability

 

decrease pain from road shock

Caster size:

stability of wheelchair

 

decrease spasms from road shock

Style:

increase shock absorbency

 

allow for feet to come under

 

durability

 

wheelchair base

 

maintenance

 

allows change in seat to floor

 

angle adjustment for posture

 

height

Spoke Protector

prevent hands from getting caught

K0065

in spokes

 

Shock absorbers

decrease vibration

 

provide smoother ride over rough

E1016 E1018

 

terrain

Push rim active assist

enable propulsion of manual

 

enable propulsion of manual

E0986

wheelchair on sloped terrain

 

wheelchair for distance

 

 

 



One armed device Left Right

enable propulsion of manual

 

unable to propel assisting with feet

E0958

wheelchair with one arm

 



Anti-tippers

prevent wheelchair from tipping

 



E0971

backward

 

 

Battery

power motor on wheelchair

 

E2360 E2361 E2632 E2363

 

 

 

E2364 E2365

 

 

 

Charger

charge battery for wheelchair

 

Attendant controlled joystick

safety

 

compliance with transportation

 

long distance driving

 

regulations

 

operation of seat functions

 



Ventilator Tray

Stabilize ventilator on wheelchair

 

E0129 E0130

 

 

 

Amputee adapter

Provide support for stump/residual

E0959

extremity

 

 

K0102 Crutch/cane holder

Stabilize accessory on wheelchair

K0104 Cylinder holder

 

 

 

K0105 IV hanger

 

 

 

Brake/wheel lock extensionR L

 

increase indep in applying wheel

 

 

 

locks

 

 

 

 

 

 

SEATING COMPONENT RECOMMENDATIONS AND JUSTIFICATION

Equipment eval/justification form

 

 

9/12

Name:

 

 

MR#:

 

Insurance/Recipient#

Component

Manufacturer

Model

Size

 

Justification

Seat Cushion

 

 

 

stabilize pelvis

 

K0108

K0669

 

 

 

accommodate obliquity

E2601

E2602

 

 

 

accommodate multiple deformity

E2603 E2604

 

 

 

neutralize LE

 

 

E2605 E2606

 

 

 

increase pressure distribution

E2607

E2608

 

 

 

accommodate impaired sensation

E2609

K0659

 

 

 

decubitus ulcers present

__________

 

 

 

prevent pelvic extension

 

 

 

 

low maintenance

 

 

 

 

 

 

 

 

Cover Replacement

 

 

 

protect back or seat cushion

K0668

 

 

 

 

 

 

Seat Platform

 

 

 

support cushion to prevent hammocking

E0992

 

 

 

 

 

 

E2618

 

 

 

 

 

 

 

Back

 

 

 

 

provide posterior trunk support

E2611 E2612

 

 

 

provide lumbar/sacral support

E2613 E2614

 

 

 

support trunk in midline

E2615 E2616

 

 

 

provide lateral trunk support

E2617 E2620

 

 

 

accommodate deformity

E2621 E0956

 

 

 

accommodate or decrease tone

K0669

 

 

 

 

facilitate tone

 

 

 

 

 

 

 

 

 

Additional pieces to

 

 

 

 

 

seat or back cushion

 

 

 

 

 

 

Mounting hardware

fixed

 

 

attach seat platform/cushion to w/c frame

lateral trunk supports

swing away

 

 

attach back cushion to w/c frame

headrest

 

E1028

 

 

swing joystick out of the way

medial thigh support

 

 

 

swing headrest away

 

joystick

 

 

 

 

swing medial thigh support away

 

 

 

 

 

 

 

Lateral pelvis/thigh

 

 

 

pelvis in neutral

accommodate pelvis

support

 

 

 

 

position upper legs

accommodate tone

E0956

 

 

 

 

removable for transfers

 

 

 

 

 

 

 

Medial Knee Support

 

 

 

decrease adduction

accommodate ROM

E0957

 

 

 

 

remove for transfers

alignment

 

 

 

 

 

 

 

Foot Support

 

 

 

position foot

accommodate deformity

K0040

 

 

 

 

stability

decrease tone

K0041

 

 

 

 

control position

 

Ankle strap/heel

 

 

 

support foot on foot support

loops

 

 

 

 

decrease extraneous movement

E0951

 

 

 

 

provide input to heel

protect foot

 

 

 

 

 

 

 

Equipment eval/justification form

10/12

Name:

 

MR#:

 

Insurance/Recipient#

 

 

 

 

 

 

Component

Manufacturer

Model

Size

 

Justification

Lateral trunk

 

 

 

decrease lateral trunk leaning

Supports

 

 

RL

accom asymmetry

E0956

 

 

 

contour for increased contact

 

 

 

 

safety

control of tone

 

 

 

 

 

Anterior chest or

 

 

 

decrease forward movement of trunk

shoulder supports

 

 

 

decrease forward movement of shoulders

E0960

 

 

 

decrease shoulder elevation

 

 

 

 

accommodation of TLSO

 

 

 

 

added abdominal support

 

 

 

 

alignment

 

 

 

 

 

assistance with shoulder control

 

 

 

 

 

Headrest

 

 

 

provide posterior head support

E0955

 

 

 

provide posterior neck support

E0996

 

 

 

provide lateral head support

K0108

 

 

 

provide anterior head support

 

 

 

 

support during tilt and recline

 

 

 

 

improve feeding

 

 

 

 

improve respiration

 

 

 

 

placement of switches

 

 

 

 

safety

 

 

 

 

 

accommodate ROM

 

 

 

 

accommodate tone

 

 

 

 

improve visual orientation

 

 

 

 

 

Neck Support

 

 

 

decrease forward neck flexion

E0996

 

 

 

decrease neck rotation

K0108

 

 

 

 

 

Upper Extremity

 

 

 

decrease gravitational pull on shoulders

Support

 

 

 

provide midline positioning

K0106

 

 

 

provide support to increase UE function

K0107

 

 

 

decrease edema

 

 

 

 

decrease subluxation

 

 

 

 

control tone

 

 

 

 

 

provide work surface

 

 

 

 

placement for AAC/Computer/EADL

 

 

 

 

 

Pelvic Positioner

 

 

 

stabilize tone

 

E0978

 

 

 

decrease falling out of chair/ **will not

K0108

 

 

 

decrease potential for sliding due to pelvic tilting

 

 

 

 

prevent excessive rotation

 

 

 

 

pad for protection over boney prominence

 

 

 

 

prominence comfort

 

 

 

 

special pull angle to control rotation

 

 

 

 

 

Equipment eval/justification form

11/12

Name:

 

MR#:

 

Insurance/Recipient#

 

 

 

 

 

 

Component

Manufacturer

Model

Size

 

Justification

Bag or pouch

 

 

 

Holds:

 

 

 

 

 

medicines

special food

 

 

 

 

orthotics

clothing changes

 

 

 

 

diapers

catheter/hygiene

 

 

 

 

ostomy supplies

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient/Client Name Printed:

Patient/Client/Caregiver

Signature:

Date:

Therapist Name Printed:

Therapist’s Signature

Date:

Supplier’s Name Printed:

Supplier’s Signature:

Date:

I agree with the above findings and recommendations of the therapist and supplier:

Physician’s Name Printed:

Physician’s Signature:

Date:

Physician Address:

Physician Phone:

Equipment eval/justification form

12/12