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SEATING AND MOBILITY EVALUATION FORM

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Wheelchair and Seating Evaluation To be completed by therapist
How does pain interfere with mobility and/or ADLs: Name: RIC MR#: Insurance/recipient # Equipment eval/justification form 4/17[PDF]
Seating/Mobility Evaluation - Illinois
HFS 3701H (R-2-08) Page 1 of 12 IL478-2431 Seating/Mobility Evaluation To be completed by Physiatrist or Physical/Occupational Therapist[PDF]
Functional Mobility & Wheelchair Assessment - Numotion
mobility device . Functional Processing Skills for Wheeled Mobility . Processing skills are adequate for safe mobility equipment operation Yes No. Patient is willing and motivated to use recommended mobility equipment Yes No Patient is . unable. to safely operate mobility equipment independently and requires . dependent care. equipment Comments:[PDF]
Seating/Mobility Evaluation - University of Pittsburgh
Seating/Mobility Evaluation Continued ADL STATUS: Indep Assist Unable Comments / Other AT Equipment Required Dressing[PDF]
Wheelchair and Seating - methodistonline
Provide dependent mobility Meet vocational / educational needs Independence with mobility in the home and/ or in the community . Independence with MRADLs in the home and/or in the community . Goals for Seating System Accommodate joint limitations : Manage LE edema from the wheelchair . Optimize pressure distribution
Wheelchair Seating Assessment Forms - The PostureWorks
Wheelchair Seating and Positioning Evaluation Short Form. 4. Wheelchair Seating and Mobility Evaluation. 5. Seating and Mobility Evaluation with Wheelchair Measurement. 6. Common Treatment Dx for Wheelchair Management. 7. Med B guidelines for Seating and Positioning Related Items. 8. ICD9 Codes for Cap Exceptions. 9. Automatic Exception Form[PDF]
Wheelchair/Scooter/Stroller Seating Assessment Form (CCP
Wheelchair/Scooter/Stroller Seating Assessment Form (CCP/Home Health Services) (8 pages) Instructions A current wheelchair/scooter/stroller seating assessment cond ucted by a physician or a physical or occupational therapist must be completed for purchase of or major mo difications (including new seating systems) to a wheeled mobility system.[PDF]
Wheelchair and Seating Assessment Guide - eMedNY
Wheelchair and Seating Assessment Guide (For sections that require justification beyond the available spacing, attach additional pages) Page 1 of 13 March 2009 . Dear Provider: Many clinicians have requested revisions to the DME Wheeled Mobility Template originally published in July 2007.[PDF]
ASSESSMENT FORM - Wheelchair Cushions
CURRENT SEATED POSITION (as best evaluated – note fixed positions) Balance/Trunk Control: Head: Neutral Hyperextended Fwd flexed Laterally flexed: R L Rotated: R L[PDF]
Custom Wheelchair Evaluation - FL Agency for Health Care
evaluation. I accept the responsibility of performing a follow-up evaluation at the time of the initial fitting and delivery of the recommended equipment and will be available for a follow-up evaluation six months after the equipment was delivered to recommend any additional adjustments, if a six-month follow up evaluation is needed.
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