Wheelchair Seating and Mobility Evaluation

A clinical intake form to document seating measurements, pressure relief needs, functional mobility, and equipment recommendations for custom mobility devices and durable medical equipment justification.

Evaluation Overview

• Evaluation date
• Referral source
• Evaluation setting
• Primary reason for evaluation
• Consent to collect and use health information for this evaluation
  This form collects protected health information (PII/PHI) only as needed to document the evaluation and support durable medical equipment justification.

Patient and Clinical Profile

• Age group
• Primary diagnosis or condition
• Secondary conditions affecting seating or mobility
• Skin integrity risk level
• Current pressure injury location

Anthropometrics and Seating Measurements

• Height (cm)
• Weight (kg)
• Hip width (cm)
• Seat depth (cm)
• Lower leg length / seat-to-footplate height (cm)
• Trunk height (cm)

Posture, Positioning, and Pressure Relief

• Pelvic alignment
• Trunk alignment
• Head control
• Pressure relief frequency
• Pressure relief method
• Postural support needs

Mobility, Transfers, and Current Equipment

• Current mobility device
• Current device limitations
• Transfer ability
• Transfer method
• Wheelchair use per day (hours)

Equipment Recommendations and Justification

• Recommended mobility base
• Recommended seating components
• Medical necessity rationale
• Expected functional outcome

Clinician Signoff

• Clinician name
• Credentials
• Clinician signature
• Date signed