Gait Trainer / Walker Assessment Form

GAIT TRAINER / WALKER ASSESSMENT FORM

A Gait Trainer/Walker is a device used for Clients with Neuromuscular conditions. Gait Trainers/Walkers and Ambulatory Programs can improve digestion, increase muscle strength, decrease contractures, increase bone density, and minimize decalcification in addition to assisting with gait training.

CLIENT: MEDICAID #: AGE:

EQUIPMENT BEING REQUESTED:

HEIGHT: WEIGHT: FLOOR to ELBOW: MID BUTTOCKS to FLOOR:

DIAGNOSIS:

CLIENT'S FUNCTIONAL LEVEL: TONE: High: ____; Low:____; Fluctuating: ____; Absent: ____ COGNITION: Normal Limits: ____; Within Functional Level: ____; Impaired Severely: _____ HEAD CONTROL: Good: ____; Fair: _____; Poor: _____ ; None: _____ TRUNK CONTROL Good: ____; Fair: _____; Poor: _____ ; None: _____ UPPER EXTREMITIES: Good: ____; Fair: _____; Poor: _____ ; None: _____ LOWER EXTREMITIES: Good: ____; Fair: _____; Poor: _____ ; None: _____

IS CLIENT EXPECTED TO AMBULATE? YES NO If yes, independent ambulation ______or assisted ambulation ______When? ______

Frequency and amount of time of the client Gait Training/Walking Program at home: (e.g., 45 minutes 3 X daily)

MINUTES X TIMES A DAY Anticipated benefits expected from Gait Trainer/Walker:

Anticipated length of time the client will require this equipment:

Anticipated changes in the client's needs, anticipated modifications or accessory needs:

Growth potential of Gait Trainer/Walker: ASSESSMENT OF CLIENT'S HOME TO ENSURE THE REQUESTED EQUIPMENT CAN BE SAFELY ACCOMMODATED AND IS USABLE IN THE HOME WITHOUT ABSTRUCTIONS. _____NO YES

SIGNATURE Physician / Therapist / QRP/RTS DATE

Clinic/School Phone Number

Standers, Gait Trainers, Walkers will not be authorized for a Client within one year of each other.

2.2.14.19.1 Medicaid Manual 2011. GAIT TRAINERS -Prior authorization may be considered with the above information.