Transcription of (Please keep in mind that a power mobility device is ...
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(Please keep in mind that a power mobility device is ...
Date: power mobility Seating and mobility Total Minutes: Seating/ mobility Evaluation Timed Minutes: (Please keep in mind that a power mobility device is covered by Medicare only if there is a documented need for it within the home.). PATIENT INFORMATION: Pt. Name: DOB: Height: Weight: MEDICAL HISTORY: What are the diagnoses that limit ambulation? Difficulty walking, Lack of coordination, generalized weakness, limited endurance pain: Osteoarthritis: What other treatments have been tried to address these symptoms? Medication Physical Therapy Surgery . WSplints Cane Walker Manual Wheelchair Are there other diagnoses that may relate to mobility problems?
Page 1 of 4 Seating/ Mobility Evaluation (Please keep in mind that a power mobility device is covered by Medicare only if there is a documented need for it within the home.) PATIENT INFORMATION:
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