Get the free MOBILITY EVALUATION FORM

272M Page 1 of 5 07/13 NEW HAMPSHIRE MEDICAID MOBILITY EVALUATION From This evaluation must be completed by a New Hampshire licensed physician, occupational therapist, or physical therapist specializing

How to fill out mobility evaluation form

How to fill out mobility evaluation form?

1. Start by reading the instructions: Before beginning to fill out the mobility evaluation form, it is important to thoroughly read and understand the provided instructions. This will help ensure that you gather all the necessary information and complete the form accurately.
2. Provide personal details: Begin by filling out your personal details such as your name, date of birth, contact information, and any other required identification information. This helps to identify the person to whom the mobility evaluation form belongs.
3. Describe your mobility concerns: The mobility evaluation form typically includes sections where you can describe your specific mobility concerns. This may involve explaining any difficulties you experience in walking, standing, climbing stairs, or performing other daily activities. Be as detailed as possible to provide a comprehensive account of your mobility issues.
4. Document medical history: It is important to provide information about your medical history as it relates to your mobility. This can include past injuries, surgeries, or any ongoing medical conditions that may affect your mobility. The evaluator needs this information to better understand your situation and provide appropriate recommendations.
5. Outline current medications and treatments: Indicate any medications you are currently taking or any ongoing treatments related to your mobility. This will give the evaluator a comprehensive understanding of your current situation and help them make informed recommendations based on your specific needs.
6. Specify assistive devices used: If you utilize any assistive devices such as canes, walkers, wheelchairs, or mobility scooters, ensure that you provide details about the devices you regularly use. Include information about the specific make, model, and usage frequency. This information is valuable for evaluating your mobility and determining if any additional or alternative devices may be beneficial.

Who needs a mobility evaluation form?

1. Individuals with mobility limitations: Anyone facing mobility limitations due to age, injury, disability, or other factors may need to fill out a mobility evaluation form. This form helps assess their specific needs and enables healthcare professionals or other evaluators to provide appropriate recommendations for improving mobility and independence.
2. Individuals seeking mobility assistance: People who are looking for assistance in enhancing their mobility may need to complete a mobility evaluation form. This could include individuals who require access to mobility aids, physical therapy, or specialized rehabilitation services.
3. Medical professionals: Healthcare providers, therapists, or other medical professionals who are evaluating a patient's mobility or prescribing assistive devices may require a mobility evaluation form. This form helps them gather necessary information to assess the patient's needs accurately and recommend appropriate interventions.

By following the step-by-step instructions and providing accurate and detailed information, you can effectively fill out a mobility evaluation form and communicate your mobility concerns and needs. Remember, the purpose of this form is to facilitate an understanding of your situation, guide recommendations, and support your journey towards improved mobility and independence.

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What is mobility evaluation form?

The mobility evaluation form is a document used to assess an individual's ability to move around and complete daily tasks independently.

Who is required to file mobility evaluation form?

Individuals who are seeking assistance with mobility or accessibility accommodations may be required to file a mobility evaluation form.

How to fill out mobility evaluation form?

The mobility evaluation form can typically be filled out by the individual seeking assistance or by a healthcare professional who has evaluated the individual's mobility needs.

What is the purpose of mobility evaluation form?

The purpose of the mobility evaluation form is to determine the level of mobility assistance or accommodations needed for an individual to maintain independence and quality of life.

What information must be reported on mobility evaluation form?

The mobility evaluation form typically requires information about the individual's current mobility challenges, any assistive devices used, and recommendations for accommodations.