Get the free Manual Wheelchair Evaluation Form

Manual Wheelchair Evaluation Form Date of Order: Patient Name: DOB: HT/WT: MOBILITY BASEJUSTIFICATIONManual Wheelchair (MWC)Seat Width q Provide transport from point A to B in the home q Promote independent

How to fill out manual wheelchair evaluation form

How to fill out manual wheelchair evaluation form

1. To fill out a manual wheelchair evaluation form, follow these steps:
2. Start by entering the client's personal information, such as name, address, and contact details.
3. Provide the client's medical history, including any diagnoses or conditions that may affect mobility or wheelchair use.
4. Assess the client's mobility needs, such as their ability to independently propel a wheelchair, transfer to and from the wheelchair, and navigate different terrains.
5. Evaluate the client's physical measurements, including height, weight, and body proportions, to determine the appropriate wheelchair size.
6. Consider the client's specific lifestyle and daily activities that may impact the selection of wheelchair features, such as tilt-in-space, recline, or elevating leg rests.
7. Identify any environmental factors that may affect wheelchair use, such as indoor or outdoor accessibility, stairs, or narrow doorways.
8. Take into account the client's preferences and goals regarding wheelchair use, comfort, and independence.
9. Conduct a comprehensive wheelchair assessment, including a trial of different wheelchair models and configurations to determine the best fit for the client.
10. Document all findings, recommendations, and considerations on the evaluation form.
11. Review the completed form with the client and involve them in the decision-making process.
12. Submit the form to the appropriate healthcare professional or wheelchair provider for further action.
13. Remember to follow any specific guidelines or protocols provided by your healthcare organization or agency.

Who needs manual wheelchair evaluation form?

1. Manual wheelchair evaluation forms are needed by healthcare professionals, therapists, and wheelchair providers who are involved in assessing and prescribing manual wheelchairs.
2. These forms help ensure that the wheelchair selected is appropriate for the individual's specific needs and abilities.
3. They are typically required for individuals who have mobility impairments or disabilities that warrant the use of a manual wheelchair.
4. Examples of individuals who may need a manual wheelchair evaluation include those with spinal cord injuries, multiple sclerosis, cerebral palsy, muscular dystrophy, amputations, or other conditions affecting mobility.
5. The evaluation form helps gather necessary information to guide the wheelchair selection process and ensure optimal mobility and independence for the user.

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