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Power wheelchair assessment form

Wheelchair assessment 2026

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The document is a Wheelchair/Scooter/Stroller Seating Assessment Form used for evaluating clients' needs for wheeled mobility systems. It outlines the requirements for a seating assessment by qualified professionals, detailing client information, neurological factors, postural control, medical history, functional assessments, environmental considerations, and requested equipment. The form includes sections for both manual and power mobility systems and emphasizes the necessity of documenting medical justifications and signatures from therapists and rehabilitation professionals.

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Click ‘Get Form’ to open the wheelchair assessment in the editor.
Begin by filling out the Client Information section. Enter the client's first name, last name, Medicaid number, date of birth, diagnosis, height, and weight.
Proceed to Section I: Neurological Factors. Indicate the client’s muscle tone and describe any active or passive movements affected by it.
In Section II: Postural Control, assess head control, trunk control, and extremities. Select the appropriate options for each category.
Move to Section III: Medical/Surgical History And Plans. Answer questions regarding skin breakdown history and describe any orthopedic conditions.
Complete Section IV: Functional Assessment by indicating ambulation status and transfer capabilities. Provide details on feeding and dressing assistance levels.
In Section V: Environmental Assessment, describe the client's living environment and accessibility features like ramps.
Fill out Section VI: Requested Equipment with details about the current seating system and medical necessity for requested equipment.
Finally, ensure all signatures are completed in Sections VII and IX by both the therapist/physician and Qualified Rehabilitation Professional (QRP).

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Versions	Form popularity	Fillable & printable
2011	4.9 Satisfied (493 Votes)

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How to be assessed for a wheelchair?

Ask a GP, physiotherapist or hospital staff to refer you to your local wheelchair service for an assessment.

What is the 6 minute wheelchair test?

Participants propel themselves in their wheelchairs at a comfortable pace while an assessor records the total distance travelled in 6 minutes. Prior to the test, the assessor will measure a fixed distance (30 meters is recommended) on a hard, flat surface.

What does a wheelchair assessment consist of?

How is a wheelchair evaluation performed? An occupational therapist or physical therapist provides a thorough evaluation which consists of assessment components including medical history, strength, range of motion, sensation and skin integrity, postural alignment, and measurements for a wheelchair seating system.

What qualifies someone for a wheelchair?

If you cant use a cane or walker safely, but you have enough upper body strength (or have someone to help you), you may qualify for a manual wheelchair. You may have to rent your manual wheelchair first, even if you eventually plan to buy it.

What qualifies for a wheelchair diagnosis?

Which Diagnoses Qualify for Custom Wheelchairs? Alzheimers Disease. ALS (Lou Gehrigs Disease) Amyotrophic Lateral Sclerosis. Anterior Horn Cell Disease. CNS Demyelination. Cerebellar Ataxia. Cerebral Palsy. Chronic Inflammatory Demyelinating Polyneuropathy.

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How do you get evaluated for a wheelchair?

In most cases the physical assessment will also include a full musculoskeletal examination of the users range of motion, joint flexibility, muscle length, and skeletal alignment, with neurological issues such as tone and spasm pattern also noted as they affect posture and muscle length.