Get Mobility-eval-1 - Tafp

The Mobility-eval-1 - Tafp form is essential for evaluating a patient's need for a power mobility device. This guide will provide you with a structured approach to completing the form with clarity and precision, ensuring all necessary information is gathered to support your assessment.

Follow the steps to fill out the Mobility-eval-1 - Tafp efficiently.

1. Click ‘Get Form’ button to access the Mobility-eval-1 - Tafp form and open it in your online editor.
2. Begin by filling out the patient information section. Include the patient’s name, health insurance claim number (HICN), mailing address, telephone number, gender, and date of birth (DOB). Ensure accuracy as this information is crucial for identification and contact purposes.
3. Proceed to the physician or treating practitioner information section. Document the name, National Provider Identifier (NPI), mailing address, and city's information. This is necessary for the evaluation’s validation.
4. Move on to the current symptoms, related diagnosis, and history section. The physician should systematically list the medical conditions that affect the patient’s mobility along with any relevant symptoms.
5. Complete the physical exam section. Document the patient's height, weight, blood pressure, and pulse rates. Indicate if the patient experiences shortness of breath at rest or with exertion, if they currently require oxygen, and any history of pressure sores or fall risks.
6. In the medications section, list all medications the patient is currently taking that are relevant to the need for a power mobility device, along with their start dates and dosages.
7. Next, fill out the history of the present problem section, detailing the patient's functional ambulatory limitations and physical limitations, providing specific descriptions for each limitation where applicable.
8. Address the ambulatory status questions. These sections require insight into how far the patient can walk and their ability to perform mobility-related activities of daily living (MRADL). Answer honestly and provide additional descriptions when the answer is 'No.'
9. Review and respond to the mobility determination questions to evaluate if the patient’s condition can be managed by mobility aids such as a cane or walker. Assess if a power wheelchair is necessary based on the limitations outlined.
10. Once all sections are completed, review the entire document for accuracy. After confirming all information is correct, you can save your changes, download, print, or share the form as needed.

Complete the Mobility-eval-1 - Tafp online to ensure accurate evaluation of mobility needs.