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Seating and Mobility Evaluation with ... - The PostureWorks

PATIENT NAME_____. PATIENT ID # _____. ASSESSMENT FORM. Name: Sex: M F DOB: Address: Phone No.: Therapist: Agency: Wheelchair being considered: Manual Elec. Assessment Date: People consulted: MEDICAL HISTORY. Diagnosis/Onset: Stable Detoriating Past Surgeries: Bone Skin Muscle Other Orthotics/Prosthetics: Medications: Medical Doctor: Ph: Health Professional(s): Ph: SOCIAL HISTORY. Lives alone Spouse Other Family Friend Other Primary Carer details: (eg general health, agency contact). Accomodation: Home/Unit Retirement Village Condo Other Ownership: Owner Rents Other Primary Living/Work Environment : (note accessibility, etc.). Narrowest Doorway: Type of setting: Rural Suburban Urban Sidewalks Paved Roads Rough Terrain Other locations where w/c will be used: Intends to use at night: Yes No Transportation : Car (passenger) Car (driver) Van Bus Taxi Other Details: FUNCTIONAL STATUS.

Bed Mobility: Bed hgt: Toiletting: Bladder: Continent Odd accident Incontinent Catheterised Intermittent catheter Bowel: Continent Odd accident Incontinent Equipment: Transfers: Seat hgt: Comments: Other Daily Activities, eg sport: PHYSICAL EVALUATION Visual Hx/Aids : Visual Scanning/Acuity/Fields : Intact Impaired Comments:

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