Get Wheelchair Assessment Form Pdf

Completing the Wheelchair Assessment Form Pdf online is an important step in obtaining the necessary equipment and services for individuals who require a wheelchair. This guide provides clear, step-by-step instructions to help users navigate through the form with ease and confidence.

Follow the steps to comprehensively complete the Wheelchair Assessment Form Pdf online.

1. Click ‘Get Form’ button to access the Wheelchair Assessment Form Pdf and open it in your preferred online document editor.
2. Begin by entering the client information. Carefully fill in the first name, last name, CSHCN Services Program number, date of birth, height, weight, address, and diagnosis (ICD-9-CM). Ensure all fields are completed accurately.
3. Move to Part I, where you will assess neurological factors. Indicate the client's muscle tone and describe any active or passive movements affected, along with the reflexes present.
4. In Part II, assess the client's postural control by indicating the control levels for the head, trunk, upper extremity, and lower extremity.
5. Proceed to Part III to document the medical and surgical history. Answer the questions regarding past skin breakdown, orthopedic conditions, physical limitations, and any anticipated surgical procedures.
6. In Part IV, complete the functional assessment by indicating the client's ambulatory status, transfer capabilities, feeding, and dressing capabilities.
7. Next, address Part V by providing an environmental assessment, including accessibility details of the client's home and school, as well as transportation logistics.
8. Then, in Part VI, describe the requested equipment, including the current seating system, reasons for the request, and any anticipated modifications within the next few years.
9. Complete Part VII only if requesting a power wheelchair. Discuss the medical necessity for the power chair, training needs, and the therapist's details.
10. Finally, review all entered information for accuracy. Save your changes, download the filled form, and prepare it for submission via mail or fax.

Start filling out the Wheelchair Assessment Form Pdf online now to ensure timely access to necessary support and resources.