Form Preview Example

Seating/Mobility Evaluation

PATIENT INFORMATION:

Name:

Date seen:

DOB:

Sex:

Address:

Physician:

Phone:

Seating Therapist:

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:

ICD9

Diagnosis:

ICD9

Diagnosis:

Code:

ICD9

Diagnosis:

ICD9

Diagnosis:

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:

House Condo/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 area Open 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:
Bowel Mngmnt: Continent	Incontinent Accidents
Bladder Mngmt: Continent	Incontinent Catheter	Comments:
Bladder Mngmt: Continent	Incontinent Catheter

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 arm: left right
							One foot:leftright Both Feet
							Safe	 Functional	Distance:
Operate Scooter							Safe	 Functional	Distance:
							Safe	 Functional	Distance:
Operate Power w/c: Std. Joystick						
Operate Power w/c: Std. Joystick

Operate Power w/c: w/ Alternative						
Operate Power w/c: w/ Alternative
Controls
Able to perform Weight Shifts/Pressure							Method:
Relief							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
F
G	C
H	C
H
I		D
I
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:

Left

Right

Functional

elev / dep

Strength concerns:

pro-retract

subluxed

ELBOWS

R.O.M.

Left

Right



Strength concerns:

WRIST

Left

Right

Strength / Dexterity:

HAND

Fisting

Anterior / Posterior

Left Right

Rotation-shoulders and

upper trunk

 Neutral

Degree of curvature: _______ o

 Left-anterior

Right-anterior





 



WFL

↑ Thoracic

↑ Lumbar

WFL

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

Anterior / Posterior

Obliquity

Rotation-Pelvis





 







Neutral

Posterior

WFL

R elev

l elev

WFL

Right

Left

Anterior Anterior

 Fixed

Other

 Fixed

Other

 Fixed

Other

 Partly Flexible



Flexible

Position

Windswept

Range

Motion





  



Neutral

ABduct

ADduct

Neutral

Right

Left

Right

WNL

Adequate

for sitting

 Fixed

Subluxed

 Fixed

Other

 Partly Flexible

 Dislocated

 Partly Flexible

Limitations

Flexible

Knee

R.O.M.

Strength concerns:

Foot Positioning

Foot Positioning Needs:

Left

Right

 WFL

L R

KNEES

 WFL

ROM concerns:

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	R L
Other:	Color:
		provide transport from point A to B		
Manufacturer:		promote Indep mobility
Model: 		is not a safe, functional ambulatory
Size: Width		is not a safe, functional ambulatory
Size: Width		
Seat Depth		
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		
		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		
E1234		transfers		
		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

Question	Answer
Form Name	Mobility Evaluation Form
Form Length	12 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min
Other names	mobility evaluation form pdf, mobility evaluation form sample, seating justification make, durable medical equipment mobility evaluation form

Mobility Evaluation Form – Fill Out and Use This PDF

Mobility Evaluation Form PDF Details

Form Preview Example

Mobility Evaluation Form isn’t the one you’re looking for?

Mobility Evaluation Form – Fill Out and Use This PDF

Mobility Evaluation Form PDF Details

Form Preview Example

Mobility Evaluation Form isn’t the one you’re looking for?

Related Documents