Get Wheelchair Seating Evaluation Form

The Wheelchair Seating Evaluation Form is a crucial document used to assess the specific needs of a person who uses a wheelchair. Filling out this form accurately helps in determining the right seating solutions required for comfort and medical necessity. This guide aims to provide clear, step-by-step instructions for completing the form online.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to retrieve the Wheelchair Seating Evaluation Form and access it in your preferred online format.
2. Begin by filling out the Client Information section, which includes critical details such as the first name, last name, Medicaid number, date of birth, diagnosis, height, and weight of the client.
3. Proceed to Section I: Neurological Factors, and indicate the client's muscle tone. Select from options like hypertonic, absent, or fluctuating, and provide descriptive responses regarding active and passive movements affected by muscle tone.
4. Move to Section II: Postural Control. Here, evaluate the client’s head, trunk, upper extremities, and lower extremities, marking their control level from good to none.
5. In Section III: Medical/Surgical History and Plans, detail any history of skin breakdown, orthopedic conditions, and recent medical changes, including anticipated surgeries.
6. Next, in Section IV: Functional Assessment, indicate the client’s ambulation potential and transfer capabilities. Provide information regarding dependence on the wheelchair and any assistance required during dressing or feeding.
7. Continue to Section V: Environmental Assessment, describing the client's home and educational settings, and assessing their accessibility for wheelchair use. Note if ramps are available in both settings.
8. For Section VI: Requested Equipment, outline the client’s current seating system, why it’s inadequate, and detail the requested equipment along with the associated medical necessity.
9. If applicable, complete Section VII for power wheelchairs, justifying the need for a power versus manual wheelchair and assessing the client's ability to operate it.
10. Conclude by ensuring all required signatures from the physician or therapist are included, as well as their contact information. Once all sections are complete, save your changes, and download or print the form as needed.

Complete your Wheelchair Seating Evaluation Form online today to ensure the proper seating solution is obtained for your needs.