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Wheelchair assessment form pdf 2025

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The document outlines the CSHCN Services Program Wheelchair Seating Evaluation Form and its instructions for completion. It provides detailed guidelines for gathering client information, assessing neurological factors, postural control, medical history, functional capabilities, environmental conditions, and requested equipment for wheelchair evaluations. The form is essential for obtaining prior authorization for durable medical equipment and must be filled out by a qualified therapist.

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Click ‘Get Form’ to open the Wheelchair Seating Evaluation Form in the editor.
Begin by filling out the 'Client Information' section. Enter the client's first name, last name, CSHCN Services Program number, date of birth, height, weight, and address. Ensure all information is printed or typed clearly.
Proceed to Part I – Neurological Factors. Indicate the client’s muscle tone and describe any active or passive movements affected by muscle tone. This section is crucial for understanding the client's needs.
In Part II – Postural Control, assess and indicate the client's head, trunk, upper extremity, and lower extremity control levels.
Continue through Parts III to VII by providing detailed medical history, functional assessments, environmental assessments, and requested equipment information as required.
Once completed, review all entries for accuracy before saving or submitting your form directly from our platform.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (140 Votes)
2016	4.1 Satisfied (67 Votes)
2009	4.9 Satisfied (54 Votes)

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What is the code for wheelchair assessment?

Overview of Code 97542 Code 97542 is used to report management of a patient using a wheelchair including assessment (eg, pos- tural/positioning needs), fitting (eg, pressure relief), and training (eg, getting in and out of the wheelchair safely and managing wheelchair propulsion on various terrains).

How to measure a patient for a wheelchair?

0:13 1:05 The second measurement we would like you to take is from the back of the bottom to the back of theMoreThe second measurement we would like you to take is from the back of the bottom to the back of the knee. Again ensuring that the tape measure does not . And is not behind the patients. Bottom.

What is the functional mobility and wheelchair assessment?

The Functional Mobility Assessment (FMA) is a measure that evaluates an individuals ability and satisfaction with a mobility device.

How long does a wheelchair assessment take?

Standard manual wheelchair assessments may take 45 minutes to an hour. Electric powered wheelchairs can take several visits to complete an assessment. Each visit can last up to an hour and a half. A therapist assessment may take up to an hour.

What is the functioning everyday with a wheelchair assessment?

The Functioning Every Day with a Wheelchair (FEW) test takes less than 15 minutes and correspondingly assesses activity while in a WC. It includes both the WC users and clinicians perspectives and measures performance in 10 different situations.

medicare wheelchair evaluation form

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What is included in functional mobility?

Functional mobility (getting from place to place while performing ADLs, such as getting into the tub, getting out of bed, moving from room to room. Functional mobility can refer to getting from place to place under your own power or with the assistance of a wheelchair or other assistive device.)

What is the functional test for mobility?

Definition: The L Test of Functional Mobility (L Test) is a performance-based measure that can be used to assess physical function, including dynamic balance ability. The test is a modification of the Timed Up and Go (TUG) designed to overcome the ceiling effect of the TUG found in higher-functioning patients.

What is involved in a wheelchair assessment?

Our wheelchair assessments includes obtaining background information; identifying problems and goals: assessing current function, posture, mobility and equipment and a physical examination/simulation, if possible; and will offer recommendations if needed.

Wheelchair assessment form pdf 2025

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