Wheeled Mobility and Seating Evaluation - Patient Intake and Wheelchair Seating Assessment Form

Oct 12, 2026

Upload by Patrick

Wheeled Mobility and Seating Evaluation is a structured form for collecting comprehensive patient and clinical information to support a wheelchair and seating assessment. It captures patient demographics, physician and therapist contacts, referral reasons, medical history including diagnoses and ICD-10 codes, relevant vitals and functional limitations, medication considerations, and current seating system details. The document also records home and community environment factors, current mobility assistive equipment condition, component issues, and patient or caregiver goals to guide recommendations.

LanguageEnglish

CategoryForms

FormatPDF

Pages17

Reading Time6 min

AccessFree to download

Patient Information

Medical History

Medical Systems and Functional Limitations

Current Mobility Assistive Equipment (MAE) / Seating

Home Environment

Community Environment

Wheeled Mobility and Seating Evaluation PATIENT INFORMATION Name DOB Sex Date Time Address City State ZIP Phone \# Spouse/Parent/Caregiver Name Phone \# Physician MD Phone \# MD NPI \# Therapist Therapist Phone \# Seating CRT Experience yrs. Medical Record \# 1º Insurance/Payor Policy \# D/C Date 2º Insurance/Payor Policy \# The following supplier ATP was present and participated in this evaluation and recommendation Name Supplier Company Phone \# Reason for Referral 􀀁 Current w/c no longer meets needs 􀀁 Current w/c beyond repair 􀀁 Ambulation not independent, safe, or timely 􀀁 Non-ambulatory 􀀁 Other Patient Goals Caregiver Goals Specific Mobility Limitations that May Affect Care Overall initial FMA Score (If applicable) 􀀁 See FMA in Medical Record 􀀁 Other outcome measure used and initial score MEDICAL HISTORY Diagnosis ICD10 Code 1º Dx Onset ICD10 Code Diagnosis ICD10 Code Diagnosis ICD10 Code Diagnosis 􀀁 Progressive Disease Relevant Past and/or Future Surgeries 􀀁 Bone 􀀁 Skin 􀀁 Muscle 􀀁 Joint 􀀁 Other _______________________________________ ______________________________________________________________________________________________________________________________________________________ Height ________ in. Weight _____ lbs. Explain recent changes or trends in weight _______________________________________________________________ Pertinent Medical History | | | | --- | --- | | Autonomic System | | | 􀀁 Intact 􀀁 Impaired 􀀁 Hx of Autonomic Dysreflexia 􀀁 Hx of Thermoregulatory Dysfunction 􀀁 Other | | | Functional Limitations
___________________________________________________________________________________________________________________________________ | | | Cardiac System
| | | Resting HR/Pulse bpm Resting BP / bpm Comments
􀀁 Intact 􀀁 Impaired 􀀁 Pacemaker 􀀁 Cardiac Precautions 􀀁 Hx of MI 􀀁 Hx of A-fib 􀀁 Tachycardia / Bradycardia 􀀁 Orthostatic Hypotension 􀀁 Syncope
􀀁 Other Functional Limitations
___________________________________________________________________________________________________________________________________ | | | Pulmonary System | | Resting Resp. Rate bpm Resting O2 Sat. % Comments 􀀁 Intact 􀀁 Impaired 􀀁 SOB 􀀁 Hx of COPD 􀀁 Hx of PE 􀀁 O2 PRN L/Min. 􀀁 O2 Dep. L/Min. 􀀁 Ventilator Dep 􀀁 Other Functional Limitations ___________________________________________________________________________________________________________________________________ Medications that may affect mobility / positioning ______________________________________________________________________________________________________________ 􀀁 See medication list in Medical Record ______________________________________________________________________________________________________________ Prosthetics, Orthotics and/or Splints Used Wheelchair and Seating Evaluation: Jill Sparacio, Jessica Pedersen, Mike Babinec, Julie Piriano (2003, 2007, 2014, 2018, 2024) Page 1 of 17 Patient Name: CURRENT MOBILITY ASSISTIVE EQUIPMENT (MAE) / SEATING Current Mobility Device 􀀁 None 􀀁 Cane 􀀁 Walker 􀀁 Stroller 􀀁 Manual W/C 􀀁 MWC w/ tilt 􀀁 MWC w/ recline 􀀁 Scooter 􀀁 Power W/C 􀀁 PWC w/ tilt 􀀁 PWC w/ recline 􀀁 PWC w/ tilt & recline 􀀁 PWC w/ Ant tilt 􀀁 PWC w/ seat elevator 􀀁 PWC w/ stand Manufacturer Model Type of control Serial \# Color Age Additional Components Condition of Current Mobility Device 􀀁 Good 􀀁 Fair 􀀁 Poor 􀀁 Disrepair 􀀁 Not safe / operational 􀀁 Irreparably damaged 􀀁 Other Problems with Current Mobility Device Seat Height in. Seat Width in. Seat Depth in. Changes needed Current Seating System Age of Seating System mo. Component Manufacturer Condition / Problems Seat Cushion Pelvic Support Lateral Hip / Thigh / Knee Support Medial Thigh Support Foot Support / Straps / H

FAQs

What patient details are collected in this evaluation form?

The form collects patient name, date of birth, sex, address, city/state/ZIP, phone contacts, physician and therapist information, and identifying medical record details.

How does the form document medical history for mobility and positioning needs?

It records diagnoses, ICD-10 codes, onset information, progressive disease status, relevant past or future surgeries, height and weight changes, and functional limitations across medical systems such as autonomic, cardiac, and pulmonary.

What wheelchair and seating information is required for the assessment?

It lists current mobility device type, manufacturer/model, serial number, condition, problems, current seat dimensions, seating system age, and detailed seating components such as cushions and supports.

Oct 12, 2026

Upload by Patrick