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Seating/Mobility Evaluation Name:Date Referred:Address:Phone:Date of Eval: Physician:Age:Sex:OT:Funding:Height:PT:Referred By:Weight:Soc. Sec. No:Reason for Referral:Patient Goals:Caregiver Goals:MEDICAL

How to fill out wheelchair evaluation form

How to fill out wheelchair evaluation form

1. Start by carefully reading all the instructions provided on the wheelchair evaluation form.
2. Fill in all the personal information fields such as name, contact details, age, and address.
3. Provide details about your medical condition and any relevant medical history that may affect your wheelchair needs.
4. If you have any specific requirements or preferences for the wheelchair, make sure to clearly mention them on the form.
5. If the form requires input from a healthcare professional, make sure to have them fill out their section accurately and sign off on the form.
6. Double-check all the information provided on the form before submitting it to ensure accuracy and completeness.

Who needs wheelchair evaluation form?

1. Individuals who are in need of a wheelchair for mobility assistance.
2. Healthcare professionals who are assessing a patient's need for a wheelchair.

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What is wheelchair evaluation form?

A wheelchair evaluation form is a document used to assess an individual's need for a wheelchair and determine the most suitable type of wheelchair for their condition.

Who is required to file wheelchair evaluation form?

Healthcare providers, such as doctors or occupational therapists, are required to file the wheelchair evaluation form on behalf of patients who need a wheelchair.

How to fill out wheelchair evaluation form?

To fill out the wheelchair evaluation form, provide detailed information regarding the patient's medical history, mobility needs, and physical limitations along with any additional documentation required.

What is the purpose of wheelchair evaluation form?

The purpose of the wheelchair evaluation form is to document the medical necessity for a wheelchair and to ensure that the appropriate model and features are selected based on the individual's needs.

What information must be reported on wheelchair evaluation form?

The form must report information such as patient demographics, medical history, functional mobility assessment, and recommended wheelchair specifications.