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Run: Wheelchair Seating and Mobility Evaluation

Document wheelchair seating measurements, posture, pressure relief needs, mobility limits, and equipment recommendations in one clinical intake form. Use it ...

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Evaluation Overview

Evaluation date (required)

Referral source (required)

Evaluation setting (required)

Primary reason for evaluation (required)

Consent to collect and use health information for this evaluation (required)

This form collects protected health information (PII/PHI) only as needed to document the evaluation and support durable medical equipment justification.

Yes No N/A

Patient and Clinical Profile

Age group (required)

Primary diagnosis or condition (required)

Secondary conditions affecting seating or mobility

Skin integrity risk level (required)

Current pressure injury location

Anthropometrics and Seating Measurements

Height (cm)

Weight (kg)

Hip width (cm) (required)

Seat depth (cm) (required)

Lower leg length / seat-to-footplate height (cm) (required)

Trunk height (cm)

Posture, Positioning, and Pressure Relief

Pelvic alignment (required)

Trunk alignment (required)

Head control (required)

Pressure relief frequency (required)

Pressure relief method

Postural support needs

Mobility, Transfers, and Current Equipment

Current mobility device (required)

Current device limitations

Transfer ability (required)

Transfer method

Wheelchair use per day (hours)

Equipment Recommendations and Justification

Recommended mobility base (required)

Recommended seating components (required)

Medical necessity rationale (required)

Expected functional outcome

Clinician Signoff

Clinician name (required)

Credentials (required)

Clinician signature (required)

Date signed (required)

Get your results

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Email (required)

Your name (optional)

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