Get Clinical Information For Wheeled Mobility

Filling out the Clinical Information for Wheeled Mobility form online is an essential step in ensuring that users receive the appropriate mobility assistance they require. This guide will provide you with clear, step-by-step instructions to navigate the form effectively and accurately.

Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the Clinical Information for Wheeled Mobility document, opening it in the online editor.
2. Begin by completing Part A, which includes the patient and provider information. Ensure all fields are filled accurately, including the patient's name, address, phone number, age, sex, height, and weight. Don’t forget to provide the information of the referring physician and occupational therapist.
3. Move to Part B to document the patient's medical history. Input the diagnosis information, including the ICD-9 codes for each condition, along with details of any recent or planned surgeries and the cardiovascular status.
4. In Part C, provide details about the current seating and mobility devices being used, including the type, manufacturer, and model of wheelchairs and cushions. Indicate the reason for any changes requested, such as replacement or repair.
5. Complete Part D by assessing the home environment. Indicate whether the entrance is wheelchair accessible and if there are any stairs. Include the width of entrances and any comments about the living situation.
6. In Part E, specify the transportation methods available to the user and any adaptations made for mobility devices. Address any specific driving, employment, or educational requirements.
7. Fill out Part F regarding cognitive and visual status by selecting the appropriate options and providing comments if necessary.
8. Proceed to Part G to assess activities of daily living (ADLs). Indicate independence levels for various activities and any adaptive equipment required.
9. In Part H, evaluate the user's mobility skills. Check the appropriate boxes to confirm abilities related to wheelchair transfers and ambulation.
10. Part I requires information on sensation. Complete this by indicating whether sensation is intact, impaired, or absent, along with comments about any history of pressure sores.
11. Fill out Part J by answering the clinical criteria questions. Each ‘yes’ or ‘no’ response should be explained accordingly.
12. Document recommendations in Part K, noting any specific equipment or personal goals that the assessments have identified.
13. Finalize any additional assessment sections as needed, including measurements and neuro-muscular status.
14. Once all sections are complete, review the form for accuracy. You may save changes, download, print, or share the completed document as necessary.

Start filling out the Clinical Information for Wheeled Mobility online today to ensure accurate and timely access to necessary mobility assistance.