Wheeled Mobility and Seating Evaluation

Wheeled Mobility and Seating Evaluation To be completed by Physiatrist, Physical Therapist or Occupational TherapistPATIENT INFORMATION Name DOB Sex Date TimeAddress 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/PayorPolicy # Phone Phone number 2º Insurance/Payor Policy # Reason for ReferralPatient GoalsCaregiver GoalsSpecific Mobility Limitations that May Affect CareMEDICAL HISTORY Diagnosis ICD9 1o Dx ICD9 Diagnosis Code Onset Code ICD9 Diagnosis ICD9 Diagnosis Code Code Progressive Disease Relevant Past and Future SurgeriesHeight Weight Explain Recent Changes or Trends in Weight Pertinent Medical HxCardiac Status Functional LimitationsIntact Impaired Severely Impaired NARespiratory Status Functional Limitations Patient Name Intact Impaired Severely Impaired O2 L / Min.OrthoticsProstheticsPage 2 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/ standType of Control Manufacturer Model Serial # Color Age Additional ComponentsSeat 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 SystemCURRENT MRADL STATUS (with present Mobility Assistive Equipment) Inde Assist Not Comments / Equipment p asses sed DressingEatingGrooming/HygienePage 3 of 25 Patient Name ToiletingBathingIADLS Bowel Mgmt Continent Incontinent Accidents CommentsBladder Mgmt Continent Incontinent Accidents CommentsDESCRIBE WHAT HAS CHANGED TO REQUIRE NEW AND/OR DIFFERENT MOBILITY ASSISTIVE EQUIPMENTPage 4 of 25 Patient Name HOME ENVIRONMENT House Condo/Town Home Apartment Asst Living LTCF SNF Own RentLives Alone / No Caregivers Lives Alone / Caregiver Asst Lives with Caregiver Hours Home Alone Comments Home is Accessible to Equipment Storage of Wheelchair In Home OtherStairs Yes No Ramp Yes NoComments COMMUNITY ADL TRANSPORTATION Car Van Public Transportation Adapted W/C Lift Ambulance Other Sits in Wheelchair During TransportTie Downs Where is W/C Stored During Transport? Self Driver Drive While in Wheelchair Yes No Passenger only Yes NoEmployment 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 ElbowGood 4 / 5 Good 4 / 5 WristFair 3 / 5 Fair 3 / 5 HandPoor 2 / 5 Poor 2 / 5 HipTrace 1/ 5 Trace 1/ 5 KneeNo Movement No Movement AnkleManual Muscle Test on file/noted on pages 6 & 7 Goniometric Measurements on file/noted on page 6 & 7Manual 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.Page 5 of 25 Patient Name CommentsBALANCE Static Sitting Dynamic Sitting Static Standing Dynamic Standing Normal / WFL Normal / WFL Normal / WFL Normal / WFLGood / Min Asst Good / Min Asst Good / Min Asst Good / Min AsstFair / Mod Asst Fair / Mod Asst Fair / Mod Asst Fair / Mod AsstPoor / Max Asst Poor / Max Asst Poor / Max Asst Poor / Max AsstUnable/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.CommentsPage 6 of 25 Patient Name VISUAL / PERCEPTUAL and SENSORY PROCESSING SKILLS Right Eye Intact Left Eye Intact Comments Vision Right Eye Impaired Left Eye ImpairedPerceptual 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.CommentsSENSATION and SKIN INTEGRITY Sensation Pressure Relief Intact Impaired Absent Able to perform effective pressure relief Yes No Method Hyposensate Hypersensate If not, Why? Please describeSkin 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 10VERBAL COMMUNICATION WFL Receptive WFL Expressive Understandable Difficult to Understand Sign Non-communicativeUses an Augmentative Communication Device Manufacturer/Model AAC Mount NeededTRANSFERS and AMBULATION Transfers Ambulation Independent Independent all Distances & Terrains Standby/Contact Asst w/ device w/o deviceMin Assist Indep. Short Distance ( ft.) Min Physical Asst w/ device w/o deviceMod Asst Indep. Smooth/Level Surfaces Mod Physical Asst w/ device w/o deviceMax Asst Indep. with Device ( ft.) Max Physical Asst w/ device w/o devicePage 7 of 25 Patient Name Dependent Unable to AmbulateSliding Board CommentsLift / Sling RequiredTimed 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 AMBULATORPage 8 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 COMMENTSMAT EVALUATIONMeasurements 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 ScapulaPage 9 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 posturePage 10 of 25 Patient Name POSTURE COMMENTS Anterior / Posterior Obliquity Rotation-Pelvis PE L V I S Neutral Posterior Anterior WFL R elev* L elev* WFL Right Left *viewed from behind Anterior AnteriorNon Reducible  Other Non Reducible  Other Non Reducible Partly Reducible Partly Reducible Other Partly Reducible Reducible Reducible ReducibleTRUNK Anterior / Posterior Left / Right Rotation-shoulders and upper trunkNeutralWFL  Thoracic  Lumbar WFL Convex Convex Left-anterior Kyphosis Lordosis Left Right c-curve s-curve multiple Right-anteriorNon Reducible  Other Non Reducible  Other Non Reducible OtherPartly Reducible Partly Reducible Partly Reducible Reducible Reducible ReduciblePosition Windswept Hip ROM LimitationsH I P    S Neutral Right Left Neutral ABduct ADduct Non Reducible Dislocated Non Reducible  OtherPartly Reducible Subluxed Partly ReducibleReducible ReducibleKnee Position Foot Position KNEES WFL L R WFL L RPage 11 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 RPartly Reducible L R Partly Reducible L R Inversion L RReducible L R Reducible L R Eversion L RDESCRIBE REFLEXES/TONAL INFLUENCE ON BODYPage 12 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 HyperextensionU 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./controlDepressed Depressed Limited UE movement/controlProtracted Protracted Absent UE movement/controlE Retracted RetractedX Subluxed SubluxedT R E M ELBOWS I Left Right T Y & Fisting FistingHANDGoals for Wheelchair Mobility Independence with mobility in the home with mobility related ADLs (MRADLs) Independence with community mobilityDependent mobility for safe transportOther – describeGoals for Seating System Optimize pressure distributionProvide support needed to facilitate function or safetyProvide corrective forces to assist with maintaining or improving postureAccommodate client’s posture- Current seated postures and positions are not reducible or will not tolerate corrective forcesClient to be independent with relieving pressure in the wheelchairPage 13 of 25 Patient Name Enhance physiological function such as breathing, swallowing, digestion and/or bowel/bladder eliminationOther – describeEQUIPMENT TRIALS AND RESULTSPage 14 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-ambulatoryLightweight Manual Wheelchair self propulsion High-strength Lightweight MWC self propulsion lifting full-time daily use requires features not available on a lightweight manual wheelchairUltra-lightweight MWC improved UE access to wheels increase chair stabilityAxle 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 chairExtra Heavy-duty MWC extreme tone/excess movementScooter/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 ofPage 15 of 25 Patient Name Stroller Base infant/child non-functional ambulator unable to propel manual non-functional UE wheelchairTilt Base or Tilt Feature Added change position against transfersForward Rearward gravitational force on head and management of tone shoulders Powered tilt on power chair change position for pressure rest periodsPowered tilt on manual chair redistribution/cannot weight shift control edemaManual tilt on manual base facilitate postural control Manual tilt on power baseRecline accommodate femur to back angle rest periodsPower 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 positioningManual recline on power basePower Seat Elevator increase Indep in transfers Power Standing Feature increase Indep in ADLsPage 16 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 transfersFoot 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 freeWheel rims/ hand rims increase self-propulsion with hand standard plastic coated other weakness/decreased grasp projections oblique verticalDrive/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 solidPage 17 of 25 Patient Name durability seat to floor height maintenance Specific seat height foot propulsion accommodation of leg length Front Back transfers postural stabilityShock absorbers decrease vibration decrease painSpoke 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 scissorExtension 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 reliefAngle 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 trayPage 18 of 25 Patient Name Page 19 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 controlUpgraded/Expandable Electronics progressive disease/changing condition to operate power seat function(s) through drive controlDisplay box to see which mode and drive the wheelchair is set necessary for alternate controlsDigital 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 modeModule 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 accessPage 20 of 25 Patient Name Attendant controlled joystick safety compliance with transportation and mount long distance driving regulations operation of seat functionsBattery 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 OtherOtherPage 21 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 deformityCustom 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 seatSeat board support cushion to prevent attach cushion/back to baseSeat platform hammocking of upholstery accommodate seat to floor heightBack boardBack 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 toneBack cushion- commercially available back cannot accommodate deformityCustom Molded Lateral pelvic / R L pelvis in neutral accommodate tone thigh support accommodate pelvis removable for transfersPage 22 of 25 Patient Name position upper legs Medial thigh decrease adduction remove for transfers support accommodate ROM alignmentFoot support R L position foot stabilityFoot box accommodate deformity decrease toneShoe holder control positionAnkle strap / support foot on foot support provide input to heel heel loops decrease extraneous movement protect footLateral 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 elevationPage 23 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 flexionUpper 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 positionPelvic 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 changesOther Other Page 24 of 25 Patient Name Follow up / Plan of CarePatient/Caregiver Signature Date Therapist Name Printed Therapist’s Signature Date Supplier’s Name Printed Supplier’s Signature DateI agree with the above findings and recommendations of the therapist and supplier Physician’s Name Printed Date Physician’s SignatureThis 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 abovePage 25 of 25

Wheeled Mobility and Seating Evaluation

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