Wheelchair Assessment Form – Fill Out and Use This PDF

Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health Services) (7 pages)

Instructions

A current wheelchair/scooter/stroller seating assessment conducted by a physician or a physical or occupational therapist must be completed for purchase of or major modifications (including new seating systems) to a wheeled mobility system. A Qualified Rehabilitation Professional (QRP) must be present and participate in the seating assessment for all wheeled mobility systems and major modifications.

Please attach manufacturer information, descriptions, and an itemized list of retail prices of all additions that are not included in base model price.

Complete Sections I-VII for manual wheeled mobility systems. Complete Sections I-IX for power wheeled mobility systems. Complete the Home Health/CCP Measuring Worksheet for all requests.

Client Information

I. Neurological Factors

Indicate client’s muscle tone: Hypertonic Absent Fluctuating Other

Describe client’s muscle tone:

Describe active movements affected by muscle tone:

Describe passive movements affected by muscle tone:

Describe reflexes present:

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II. Postural Control

Head control:	Good	Fair	Poor	None
Trunk control:	Good	Fair	Poor	None
Upper extremities:	Good	Fair	Poor	None
Lower extremities:	Good	Fair	Poor	None

III. Medical/Surgical History And Plans:

Describe orthopedic conditions and/or range of motion limitations requiring special consideration (i.e., contractures, degree of spinal curvature, etc.):

Describe other physical limitations or concerns (i.e., respiratory):

Describe any recent or expected changes in medical/physical/functional status:

If surgery is anticipated, please indicate the procedure and expected date:

IV. Functional Assessment:

Ambulatory status:	Nonambulatory	With assistance
	Short distances only	Community ambulatory
Indicate the client’s ambulation	Expected within 1 year
potential:	Not expected
	Expected in future within ___ years

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IV. Functional Assessment:

Wheelchair Ambulation:
Is client totally dependent upon wheelchair?			Yes	No
If no, please explain:
Indicate the client’s transfer		Maximum assistance			Moderate assistance
capabilities:		Minimum assistance			Independent
Is the client tube fed?	Yes	No
If yes, please explain:
Feeding:		Maximum assistance			Moderate assistance
		Minimum assistance			Independent
Dressing:		Maximum assistance			Moderate assistance
		Minimum assistance			Independent
Describe other activities performed while in wheelchair:

V. Environmental Assessment

Describe where client resides:

Is the home accessible to the wheelchair?	Yes	No
Are ramps available in the home setting?	Yes	No
Describe the client’s educational/vocational setting:
Is the school accessible to the wheelchair?	Yes	No
Are there ramps available in the school setting?	Yes	No
If client is in school, has a school therapist been involved in the assessment?			Yes	No
Name of school therapist:
Name of school:

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V. Environmental Assessment

School therapist’s telephone number:

Describe how the wheelchair will be transported:

Describe where the wheelchair will be stored (home and/or school):

Describe other types of equipment which will interface with the wheelchair:

VI. Requested Equipment:

Describe client’s current seating system, including the mobility base and the age of the seating system:

Describe why current seating system is not meeting client’s needs:

Describe the equipment requested:

Describe the medical necessity for mobility base and seating system requested:

Describe the growth potential of equipment requested in number of years:

Describe any anticipated modifications/changes to the equipment within the next three years:

VII: Signatures of Therapist/Physician and Qualified Rehabilitation Professional (QRP)

Physician/Therapist’s name:			Physician/Therapist’s signature:
Physician/Therapist’s title:			Date:
Physician/Therapist’s telephone number: (	)	-

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Physician/Therapist’s employer (name):	Physician/Therapist’s address (work or employer
	address):
QRP Name:	NPI:	TPI:
QRP Signature:	Date:

VIII. POWER WHEELCHAIRS:

Complete if a power wheelchair is being requested

Describe the medical necessity for power vs. manual wheelchair: (Justify any accessories such as power tilt or recline)

Is client unable to operate a manual chair even when adapted?	Yes	No
Is self propulsion possible but activity is extremely labored?	Yes	No
If yes, please explain:

How will the power wheelchair be operated (hand, chin, etc.)?

Has the client been evaluated with the proposed drive controls?

Does the client have any condition that will necessitate possible change in access or drive controls within the next five years?

Is the client physically and mentally capable of operating a power wheelchair safely and with respect to others?

Yes

No

Is the caregiver capable of caring for a power wheelchair and understanding how it operates?

How will training for the power equipment be accomplished?

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IX: Signatures of Therapist/Physician and Qualified Rehabilitation Professional (QRP)

Physician/Therapist’s name:			Physician/Therapist’s signature:
Physician/Therapist’s title:			Date:
Physician/Therapist’s telephone number: (	)	-
Physician/Therapist’s employer (name):	Physician/Therapist’s address (work or employer address):

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Home Health/CCP Measuring Worksheet

General Information

Client’s name:	Date of birth:
Client’s Medicaid number:	Height:
Date when measured:	Weight:

Measurements

	1:	Top of head to bottom of
		buttocks
	2:	Top of shoulder to bottom of
		buttocks
	3:	Arm pit to bottom of
		buttocks
	4:	Elbow to bottom of buttocks
	5:	Back of buttocks to back of
		knee
	6:	Foot length
	7:	Head width
	8:	Shoulder width
	9:	Arm pit to arm pit
	10:	Hip width
	11:	Distance to bottom of left leg
		(popliteal to heel)
	12:	Distance to bottom of right
		leg (popliteal to heel)

Additional Comments

Signatures of Measurer and Qualified Rehabilitation Professional (QRP)

Measurer’s Name

Measurer’s Signature:			Date:
Measurer’s Telephone number: (	)	-
QRP Name:

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