Wheeled Mobility and Seating Evaluation

Wheeled Mobility and Seating Evaluation To be completed by Physiatrist, Physical Therapist or Occupational Therapist

PATIENT INFORMATION Name DOB Sex Date Time

Address Physician This evaluation / justification form will serve as the LMN for MD NPI # the following supplier MD Phone Phone Therapist Contact Person Spouse/Parent/Caregiver name 1º Insurance/Payor

Policy # Phone Phone number 2º Insurance/Payor 

Policy # Reason for Referral

Patient Goals

Caregiver Goals

Specific Mobility Limitations that May Affect Care

MEDICAL HISTORY Diagnosis ICD9 1o Dx ICD9 Diagnosis Code Onset Code ICD9 Diagnosis ICD9 Diagnosis Code Code Progressive Disease Relevant Past and Future Surgeries

Height Weight Explain Recent Changes or Trends in Weight

Pertinent Medical Hx

Cardiac Status Functional Limitations

Intact Impaired Severely Impaired NA

Respiratory Status Functional Limitations Patient Name

Intact Impaired Severely Impaired O2 L / Min.

Orthotics

Prosthetics

of 25 Patient Name

CURRENT SEATING / MOBILITY Current Mobility Base None Stroller Manual w/c Manual with tilt Manual with recline Scooter

Power Power w/ tilt Power w/ recline Power w/ tilt & recline w/ seat elevator w/ stand

Type of Control Manufacturer Model Serial # Color Age Additional Components

Seat Height Seat Width Seat Depth Condition of Current Mobility Base Problems with Current Mobility Base

Current Seating System Age of Seating System COMPONENT MANUFACTURER / CONDITION Seat Base Mounting Hardware Cushion Pelvic Support Thigh Support Knee Support Foot Support Foot Strap / Heel Loop Back Mounting Hardware Lateral Trunk Supports Chest / Shoulder Support Head Support Mounting Hardware UE Support Mounting Hardware Other Other When Relevant Overall Seat Height Overall W/C Length Overall W/C Width Describe Posture in Present Seating System

CURRENT MRADL STATUS (with present Mobility Assistive Equipment) Inde Assist Not Comments / Equipment p asses sed Dressing

Eating

Grooming/Hygiene

of 25 Patient Name Toileting

Bathing

IADLS Bowel Mgmt Continent Incontinent Accidents Comments

Bladder Mgmt Continent Incontinent Accidents Comments

DESCRIBE WHAT HAS CHANGED TO REQUIRE NEW AND/OR DIFFERENT MOBILITY ASSISTIVE EQUIPMENT

of 25 Patient Name

HOME ENVIRONMENT House Condo/Town Home Apartment Asst Living LTCF SNF Own Rent

Lives Alone / No Caregivers Lives Alone / Caregiver Asst Lives with Caregiver Hours Home Alone

Comments Home is Accessible to Equipment Storage of Wheelchair In Home Other

Stairs Yes No Ramp Yes No

Comments

COMMUNITY ADL TRANSPORTATION Car Van Public Transportation Adapted W/C Lift Ambulance Other Sits in Wheelchair During Transport

Tie Downs Where is W/C Stored During Transport? Self Driver Drive While in Wheelchair Yes No Passenger only Yes No

Employment Specific requirements pertaining to mobility

School Specific requirements pertaining to mobility Other

STRENGTH / RANGE OF MOTION Gross Overall Strength Gross Range of Motion Upper Extremity Lower Extremity Shoulder

Normal 5 / 5 Normal 5 / 5 Elbow

Good 4 / 5 Good 4 / 5 Wrist

Fair 3 / 5 Fair 3 / 5 Hand

Poor 2 / 5 Poor 2 / 5 Hip

Trace 1/ 5 Trace 1/ 5 Knee

No Movement No Movement Ankle

Manual Muscle Test on file/noted on pages 6 & 7 Goniometric Measurements on file/noted on page 6 & 7

Manual Muscle Test not on file Goniometric Measurements not on file

Patient has sufficient strength and range of motion to ambulate and participate in MRADLs.

Patient does not have sufficient strength and/or range of motion to ambulate and participate in MRADLs.

Patient has sufficient strength and range of motion to propel a manual W/C and participate in MRADLs.

Patient does not have sufficient strength and/or range of motion to propel a manual W/C and participate in MRADLs.

Patient has sufficient strength and range of motion to operate a POV and participate in MRADLs.

Patient does not have sufficient strength and/or range of motion to operate a POV and participate in MRADLs.

of 25 Patient Name Comments

BALANCE Static Sitting Dynamic Sitting Static Standing Dynamic Standing Normal / WFL Normal / WFL Normal / WFL Normal / WFL

Good / Min Asst Good / Min Asst Good / Min Asst Good / Min Asst

Fair / Mod Asst Fair / Mod Asst Fair / Mod Asst Fair / Mod Asst

Poor / Max Asst Poor / Max Asst Poor / Max Asst Poor / Max Asst

Unable/Dependant Unable/Dependant Unable/Dependant Unable/Dependant

Patient has sufficient balance to ambulate and participate in MRADLs.

Patient does not have sufficient balance to ambulate and participate in MRADLs.

Patient has sufficient balance to propel a manual W/C to participate in MRADLs.

Patient does not have sufficient balance to propel a manual W/C to participate in MRADLs.

Patient has sufficient balance and endurance to operate a POV and participate in MRADLs.

Patient does not have sufficient balance and/or endurance to operate a POV and participate in MRADLs.

Comments

of 25 Patient Name

VISUAL / PERCEPTUAL and SENSORY PROCESSING SKILLS Right Eye Intact Left Eye Intact Comments Vision Right Eye Impaired Left Eye Impaired

Perceptual Perceptual Skills Intact Perceptual Skills Impaired Comments

Motor Planning Intact Impaired N/A or NT Comments

Handedness Right Left N/A Comments

Patient has sufficient vision, perception and motor planning to operate MAE and participate in MRADLs.

Patient does not have sufficient vision, perception and/or motor planning to safely operate MAE and participate in MRADLs.

Comments

SENSATION and SKIN INTEGRITY Sensation Pressure Relief Intact Impaired Absent Able to perform effective pressure relief Yes No Method Hyposensate Hypersensate If not, Why? Please describe

Skin Issues / Skin Integrity Current Skin Integrity History of Skin Issues Yes No Hx of Skin Surgery Yes No Intact Red Area Open Area

Where Where Where When When Size Scar Tissue At Risk -Prolonged Sitting Limited Sitting Tolerance Yes No Hours per Day Braden Score, if administered Complaint of Pain 0 1 2 3 4 5 6 7 8 9 10

VERBAL COMMUNICATION WFL Receptive WFL Expressive Understandable Difficult to Understand Sign Non-communicative

Uses an Augmentative Communication Device Manufacturer/Model

AAC Mount Needed

TRANSFERS and AMBULATION Transfers Ambulation Independent Independent all Distances & Terrains Standby/Contact Asst w/ device w/o device

Min Assist Indep. Short Distance ( ft.) Min Physical Asst w/ device w/o device

Mod Asst Indep. Smooth/Level Surfaces Mod Physical Asst w/ device w/o device

Max Asst Indep. with Device ( ft.) Max Physical Asst w/ device w/o device

of 25 Patient Name Dependent Unable to Ambulate

Sliding Board Comments

Lift / Sling Required

Timed Up and Go Test sec. [60-69 y 8.1sec (7.1-9.0), 70-79 y 9.2 sec (8.2-10.2), 70-99 y 11.3 sec (10.0-12.7)]

EXPLAIN WHY PATIENT IS NON-AMBULATORY or NOT A FUNCTIONAL AMBULATOR

of 25 Patient Name

WHEELCHAIR SKILLS (Shown by Trial) Indep Assist Dependent N/A Comments /Unable Manual W/C Propulsion Safe Functional Distance

UE or LE strength and endurance is sufficient to Method

participate in MRADLs using a manual wheelchair Arm Left Right Both UE or LE strength and/or endurance is not sufficient to Foot Left Right Both participate in MRADLs using a manual wheelchair Operate Scooter Safe Functional Distance

Strength, hand grip, balance, control & transfers are appropriate for scooter use.

Strength, hand grip, balance, control or transfers are not appropriate for scooter use.

Living environment is appropriate for scooter use.

Living environment is not appropriate for scooter use.

Operate PWC w/ Joystick & Standard Safe Functional Distance Programming Operate PWC w/ Joystick & Advanced Safe Functional Distance Programming Operate PWC w/ Alternative Control Safe Functional Distance

COMMENTS

MAT EVALUATION

Measurements in Sitting Left Right A Shoulder Width H Seat to Top of Shoulder B Chest Width I Acromium Process (Tip of Shoulder) C Chest Depth (Front – Back) J Inferior Angle of Scapula

of 25 Patient Name D Hip width K Seat to Iliac Crest E Between Knees L Seat to Elbow F Top of Head M Upper leg length G Occiput N Lower leg length + Overall width (asymmetrical width for O Foot Length + windswept legs or scoliotic posture

of 25 Patient Name

POSTURE COMMENTS Anterior / Posterior Obliquity Rotation-Pelvis P

E L V I S Neutral Posterior Anterior WFL R elev* L elev* WFL Right Left *viewed from behind Anterior Anterior

Non Reducible  Other Non Reducible  Other Non Reducible

Partly Reducible Partly Reducible Other Partly Reducible Reducible Reducible Reducible

TRUNK Anterior / Posterior Left / Right Rotation-shoulders and upper trunk

Neutral

WFL  Thoracic  Lumbar WFL Convex Convex Left-anterior Kyphosis Lordosis Left Right c-curve s-curve multiple Right-anterior

Non Reducible  Other Non Reducible  Other Non Reducible Other

Partly Reducible Partly Reducible Partly Reducible

Reducible Reducible Reducible

Position Windswept Hip ROM Limitations

H I P    S Neutral Right Left Neutral ABduct ADduct Non Reducible Dislocated Non Reducible  Other

Partly Reducible Subluxed Partly Reducible

Reducible Reducible

Knee Position Foot Position KNEES WFL L R WFL L R

of 25 Patient Name & Limitations L R Limitations L R Dorsi-Flexed L R FEET Non Reducible L R Non Reducible L R Plantar Flexed L R

Partly Reducible L R Partly Reducible L R Inversion L R

Reducible L R Reducible L R Eversion L R

DESCRIBE REFLEXES/TONAL INFLUENCE ON BODY

of 25 Patient Name

POSTURE COMMENTS Functional Good Head control Describe Tone//Movement of Head and Neck HEAD Flexed Extended Adequate Head Contol

& Rotated L Rotated R Limited Head Control NECK Lat Flexed Lat Flexed L Absent Head Control R Cervical Hyperextension

U SHOULDERS Describe Tone/Movement P Left Right of the Upper Extremities P E Functional Functional Good UE movement/control R Elevated Elevated Functional UE mvmt./control

Depressed Depressed Limited UE movement/control

Protracted Protracted Absent UE movement/control

E Retracted Retracted

X Subluxed Subluxed

T R E M ELBOWS I Left Right T Y & Fisting Fisting

Goals for Wheelchair Mobility Independence with mobility in the home with mobility related ADLs (MRADLs)

Independence with community mobility

Dependent mobility for safe transport

Other – describe

Goals for Seating System Optimize pressure distribution

Provide support needed to facilitate function or safety

Provide corrective forces to assist with maintaining or improving posture

Accommodate client’s posture- Current seated postures and positions are not reducible or will not tolerate corrective forces

Client to be independent with relieving pressure in the wheelchair

of 25 Patient Name Enhance physiological function such as breathing, swallowing, digestion and/or bowel/bladder elimination

Other – describe

EQUIPMENT TRIALS AND RESULTS

of 25 Patient Name

MOBILITY BASE RECOMMENDATIONS and JUSTIFICATION MOBILITY BASE JUSTIFICATION Manufacturer provide transport from point A to B width/depth necessary to Model Color promote independent mobility accommodate anatomical Seat Width measurement Seat Depth not a safe, functional ambulator

Length of need walker or cane inadequate

non-ambulatory

Lightweight Manual Wheelchair self propulsion

High-strength Lightweight MWC self propulsion lifting

full-time daily use requires features not available

on a lightweight manual wheelchair

Ultra-lightweight MWC improved UE access to wheels increase chair stability

Axle position adjustment efficient propulsion change angle for improved vertical (dump) horizontal postural stability rotational (camber)

Heavy-duty Manual Wheelchair user weight broken frame on previous chair

Extra Heavy-duty MWC extreme tone/excess movement

Scooter/POV non-ambulatory has adequate trunk stability

non-functional ambulator can safely operate & is willing to

cannot functionally propel manual can safely transfer

wheelchair

Power Wheelchair non-ambulatory requires speed adjustment

non-functional ambulator requires torque adjustability

cannot functionally propel manual requires sensitivity adjustability

wheelchair requires acceleration cannot functionally and safely adjustability operate scooter/POV requires braking adjustability home environment does not requires expandable electronics support the use of a POV requires alternative drive control can safely operate & is willing to required to negotiate an incline can safely transfer of required to negotiate a rise of

of 25 Patient Name Stroller Base infant/child non-functional ambulator

unable to propel manual non-functional UE

wheelchair

Tilt Base or Tilt Feature Added change position against transfers

Forward Rearward gravitational force on head and management of tone shoulders Powered tilt on power chair change position for pressure rest periods

Powered tilt on manual chair redistribution/cannot weight shift control edema

Manual tilt on manual base facilitate postural control

Manual tilt on power base

Recline accommodate femur to back angle rest periods

Power recline on power base bring to full recline for ADL care repositioning for transfers or

Power recline on manual base change position for pressure clothing/diaper/catheter management Manual recline on manual base redistribution/cannot weight shift head positioning

Manual recline on power base

Power Seat Elevator increase Indep in transfers

Power Standing Feature increase Indep in ADLs

of 25 Patient Name

MOBILITY BASE COMPONENTS JUSTIFICATION Armrests provide support with elbow at 90 remove for transfers fixed adjustable height removable provide support for w/c tray allow to come closer to table top swing away flip back reclining change height/angle for ADLs remove for access to tables full length desk length tubular

Footrests/ Leg rests provide LE support manage tone/spasticity 60 70 80 90 heavy duty accommodate knee ROM enable lateral transfers fixed lift off swing away elevate legs w/tilt and/or recline decrease edema elevating articulating elevating provide change in position for legs physically unable to operate power elevating legrests maintain feet on footplate manual elevating legrests power articulating elevating legrests

Foot Platform provide LE support elevate legs w/ tilt and/or recline flip up power elevating accommodate hip abduction change in position for legs power articulating elevating minimize turning radius decrease edema

maintain feet on footplate

enable transfers

Foot support provide foot support transfers flip up fixed/rigid accommodate ankle ROM adjustable angle R L allow foot to go under w/c base multi-adjustable angle R L

Drive/propulsion wheel size increase access to wheel increase propulsion ability Wheel style mag spokes allow seating system to fit on base maintenance free

Wheel rims/ hand rims increase self-propulsion with hand standard plastic coated other weakness/decreased grasp projections oblique vertical

Drive/propulsion tires decrease maintenance decrease pain pneumatic semi-pneumatic prevent frequent flats decrease spasms flat free inserts solid increase shock absorbency

Caster housing maneuverability decrease pain Caster size Style stability of wheelchair decrease spasms pneumatic semi-pneumatic increase shock absorbency allow feet under wheelchair base flat free inserts solid

of 25 Patient Name durability seat to floor height

maintenance

Specific seat height foot propulsion accommodation of leg length Front Back transfers

postural stability

Shock absorbers decrease vibration

decrease pain

Spoke protector protect hand/fingers from spokes

Side guards prevent skin tears/abrasions

One armed drive attachment R L enable propulsion of manual

wheelchair with one arm Anti-tippers prevent rearward displacement

Amputee adapter increase rearward stability

Wheel locks indep in applying wheel locks push pull scissor

Extension R L

Transportation tie-down option provide crash tested brackets

Push handles caregiver access allows “hooking” to enable extended angle adjustable caregiver assist increased ability to perform ADLs, standard maintain balance or pressure relief

Angle adjustable back postural control UE functional control

control of tone/spasticity accommodate seating system

accommodate range of motion

Crutch/Cane holder IV hanger

Cylinder holder Vent tray

of 25 Patient Name

of 25 Patient Name MOBILITY BASE COMPONENTS JUSTIFICATION POWER WHEELCHAIR CONTROLS provides access for controlling Proportional wheelchair Type

Body Part(s) Left Right

lacks motor control to operate

Non-Proportional/switches proportional drive control Type unable to understand proportional controls Body Part(s) programming for accurate control

Upgraded/Expandable Electronics progressive disease/changing

condition to operate power seat function(s)

through drive control

Display box to see which mode and drive the wheelchair is set necessary for alternate controls

Digital Interface Electronics to allow the w/c to operate when

using alternative drive controls Head Array to operate wheelchair through

switches placed in tri-panel headrest Sip and puff w/ Tubing Kit needed to operate sip and puff

drive controls Upgraded Tracking Electronics increase safety when driving

correct tracking when on uneven

Safety Reset Switches surfaces

to change modes and stop the

Single or Multiple Actuator Control wheelchair when driving in latch mode

Module to operate the power seat

function(s) through the drive control Mount for switches or joystick attaches switches to w/c midline for optimal placement

swing away for safe transfers provides for consistent access

of 25 Patient Name Attendant controlled joystick safety compliance with transportation and mount long distance driving regulations

operation of seat functions

Battery power motors on wheelchair

Charger charge battery for wheelchair

Push rim active assist enable propulsion of manual enable propulsion of manual

wheelchair on sloped terrain wheelchair for distance Other

of 25 Patient Name

SEATING / POSITIONING COMPONENT RECOMMENDATIONS AND JUSTIFICATION COMPONENT Mfg/model/size JUSTIFICATION Seat cushion impaired sensation stabilize pelvis

decubitus ulcers present prevent pelvic extension

history of decubitus ulcers accommodate obliquity/rotation

increase pressure distribution accommodate multiple deformity

neutralize LE

Seat cushion- commercially available cushion cannot accommodate deformity

Custom Molded

Seat wedge accommodate ROM

aggressive seat shape to

decrease sliding down in the seat Cover replacement protect back or seat cushion

Mounting hardware fixed attach seat platform/cushion swing-away for safe transfers

lateral supports attach back platform/cushion flip-down/away for safe transfers swing headrest mount postural support(s) multi-axis for accurate positioning away medial thigh support & removal for safe transfers

back seat

Seat board support cushion to prevent attach cushion/back to base

Seat platform hammocking of upholstery accommodate seat to floor height

Back board

Back cushion provide posterior trunk support provide lumbar/sacral support

provide posterior/lateral trunk support trunk in midline

support pressure relief over spinous accommodate deformity processes accommodate or decrease tone

facilitate tone

Back cushion- commercially available back cannot accommodate deformity

Custom Molded

Lateral pelvic / R L pelvis in neutral accommodate tone

thigh support accommodate pelvis removable for transfers

of 25 Patient Name position upper legs

Medial thigh decrease adduction remove for transfers

support accommodate ROM alignment

Foot support R L position foot stability

Foot box accommodate deformity decrease tone

Shoe holder control position

Ankle strap / support foot on foot support provide input to heel

heel loops decrease extraneous movement protect foot

Lateral trunk R L decrease lateral trunk leaning safety

supports accommodate asymmetry control of tone

contour for increased contact

Anterior chest decrease forward movement of added abdominal support

strap, vest, or shoulder alignment shoulder retractors accommodation of TLSO assistance with shoulder control decrease forward movement of trunk decrease shoulder elevation

of 25 Patient Name COMPONENT Mfg/model/size JUSTIFICATION Headrest provide posterior head improve respiration

support placement of switches provide posterior neck safety support provide lateral head accommodate ROM

support accommodate tone provide anterior head improve visual support support during tilt and orientation

recline improve feeding

Neck support decrease neck rotation decrease forward neck

flexion

Upper extremity R L decrease edema decrease gravitational

support decrease subluxation pull on shoulders Arm trough provide midline control tone ______Hand support positioning provide work surface provide support for UE ½ tray placement for function Full tray provide hand support in AAC/Computer/EADL Swivel mount natural position

Pelvic positioner stabilize tone pad for protection over boney

Single pull belt decrease falling out of chair prominence prominence comfort Specialized belt prevent excessive rotation special pull angle to control SubASIS bar /other rotation Essential needs Holds diapers catheter/hygiene medicines special food bag or pouch ostomy supplies orthotics clothing changes

Other Other

of 25 Patient Name Follow up / Plan of Care

Patient/Caregiver Signature Date Therapist Name Printed Therapist’s Signature Date Supplier’s Name Printed Supplier’s Signature Date

I agree with the above findings and recommendations of the therapist and supplier Physician’s Name Printed Date Physician’s Signature

This is to certify that I, the above signed therapist have the following affiliations This DME Supplier

Manufacturer of Recommended Equipment

Patient’s Long Term Care Facility

None of the above