Get Wheelchair Scooter Stroller Seating Assessment Form

Filling out the wheelchair scooter stroller seating assessment form online can streamline the process of obtaining necessary mobility equipment. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently, ensuring that all relevant information is included.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the client information, including the first name, last name, Medicaid number, date of birth, diagnosis, height, and weight in the designated fields.
3. Proceed to section I, where you will indicate the neurological factors such as muscle tone. Select applicable options and provide descriptions for muscle tone, active and passive movements, and reflexes.
4. Continue to section II to assess postural control. For head, trunk, upper extremities, and lower extremities, choose the appropriate control level (Good, Fair, Poor, None) and provide any necessary details.
5. In section III, provide medical and surgical history. Indicate if there are any histories of skin breakdown or orthopedic conditions, and detail any expected changes in medical status.
6. Move to section IV, focusing on functional assessment. Indicate ambulatory status, transfer capabilities, and describe any feeding, dressing, or other activities performed while in a wheelchair.
7. In section V, evaluate the environmental assessment. Describe the client’s living situation, accessibility of the home and school, and any available ramps.
8. Section VI is for requested equipment. Describe the current seating system, explain its inadequacies, and detail the requested equipment and its medical necessity.
9. Fill in section VII with the required signatures and information of the therapist or physician, including their title, date, and contact information.
10. For power wheelchairs, complete section VIII, justifying the medical necessity and detailing any conditions or capabilities regarding power vs. manual operation.
11. Finally, review all information for accuracy, then save changes, download, print, or share the form as needed.

Complete your documents online for a smoother, more efficient process.