Get Mobility Evaluation Report For Scooter

The Mobility Evaluation Report for Scooter is an essential document that enables practitioners to assess and document the mobility needs of individuals requiring powered mobility equipment. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the Mobility Evaluation Report for Scooter online.

1. Click 'Get Form' button to obtain the Mobility Evaluation Report for Scooter and open it in your preferred online editor.
2. Begin filling out the Date of Request field at the top of the form. Enter the current date when completing the report.
3. Indicate whether this is an initial request or a replacement by selecting the appropriate box.
4. Provide the member's name and unique member ID number in the designated fields to identify the individual.
5. Fill out the contact information for the Durable Medical Equipment (DME) provider, including the provider's name, contact phone number, and fax number.
6. In the Current Symptoms, Related Diagnosis, and History section, underline the medical conditions or diseases that limit the individual's mobility within their home setting.
7. Detail how the listed conditions interfere with the individual's ability to perform activities of daily living by checking relevant symptoms.
8. Enter data regarding the physical exam, including height, weight, and whether the patient experiences shortness of breath at rest or with exertion.
9. Indicate the patient's functional capacity by marking relevant responses regarding their ability to shift weight, balance, and history of falls.
10. Complete the Scooter Mobility Evaluation sections by selecting the daily activities the patient cannot perform and explaining why standard mobility aids would not suffice.
11. Answer the questions regarding the patient's ability to sit erect, their capacity to safely operate a scooter, and their willingness to use one.
12. Finalize the form by having the treating practitioner certify the information provided with their signature and date.

Start filling out the Mobility Evaluation Report for Scooter online today!