Get Electric Wheelchair Evaluation Form

Filling out the Electric Wheelchair Evaluation Form accurately is crucial for ensuring that individuals receive the appropriate mobility assistive equipment. This guide provides a comprehensive, step-by-step approach to help you navigate the online form with ease.

Follow the steps to successfully complete the Electric Wheelchair Evaluation Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the patient’s information section, including the patient's name, date of evaluation, HIC number, date of birth, height, and weight.
3. Provide the patient’s address, including city, state, and zip code.
4. Indicate the type of equipment that has been ordered by the practitioner and the date of the face-to-face examination.
5. Complete the medical history section by listing the patient's mobility limitations and any relevant diagnoses.
6. Respond to questions regarding any limitations related to mobility-related activities of daily living (MRADLs) and describe the patient’s mental or cognitive status by checking the applicable boxes.
7. Assess whether the mobility assistive equipment can be used safely and effectively with the assistance of a caregiver, if applicable.
8. In the functional assessment section, detail the patient's ambulatory status and the capabilities for wheelchair ambulation.
9. Evaluate the home environmental assessment by describing the patient's residence, accessibility, and potential modifications required.
10. Fill out the patient measuring worksheet if applicable, providing details about upper extremity function and ability to operate power-operated equipment.
11. Provide recommendations as an evaluating technician, listing necessary equipment alternatives and justifications.
12. Complete the physician notes section if any discrepancies exist and ensure all signatures are provided.
13. Once completed, review the filled-out form for accuracy and clarity, then save changes, download, print, or share the form as needed.

Start completing your Electric Wheelchair Evaluation Form online today for efficient processing of mobility assistive equipment.