Wheelchair Scooter Stroller Seating Assessment Form - Fill ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. Proceed to Section I: Neurological Factors. Indicate the client’s muscle tone and describe any active or passive movements affected by muscle tone.
4. In Section II: Postural Control, assess head control, trunk control, and extremities. Select the appropriate options for each category.
5. Complete Section III: Medical/Surgical History And Plans by answering questions regarding decubitus history and orthopedic conditions.
6. Continue to Section IV: Functional Assessment. Provide details on ambulation status and wheelchair dependency.
7. Fill out Section V: Environmental Assessment by describing the client's living environment and accessibility features.
8. In Section VI: Requested Equipment, detail the current seating system and justify the medical necessity for requested equipment.
9. 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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