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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. 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Weight  \n_____  \nlbs. Explain recent changes or trends in weight  \n_______________________________________________________________  \nPertinent Medical History  \n\n|  |  |\n| --- | --- |\n| Autonomic System |  |\n| 􀀁 Intact 􀀁 Impaired 􀀁 Hx of Autonomic Dysreflexia 􀀁 Hx of Thermoregulatory Dysfunction 􀀁 Other   |  |\n| Functional Limitations  \u003Cbr>___________________________________________________________________________________________________________________________________ |  |\n| Cardiac System\u003Cbr>|  |\n| Resting HR/Pulse   bpm Resting BP   /   bpm Comments  \u003Cbr>􀀁 Intact 􀀁 Impaired 􀀁 Pacemaker 􀀁 Cardiac Precautions 􀀁 Hx of MI 􀀁 Hx of A-fib 􀀁 Tachycardia / Bradycardia 􀀁 Orthostatic Hypotension 􀀁 Syncope\u003Cbr>􀀁 Other   Functional Limitations  \u003Cbr>___________________________________________________________________________________________________________________________________ |  |\n| Pulmonary System |  |\n\nResting Resp. Rate   bpm Resting O2 Sat.   % Comments    \n􀀁 Intact 􀀁 Impaired 􀀁 SOB 􀀁 Hx of COPD 􀀁 Hx of PE 􀀁 O2 PRN   L/Min. 􀀁 O2 Dep.   L/Min. 􀀁 Ventilator Dep  \n􀀁 Other   Functional Limitations    \n___________________________________________________________________________________________________________________________________  \nMedications that may affect mobility / positioning  \n______________________________________________________________________________________________________________  \n􀀁 See medication list in Medical Record    \n______________________________________________________________________________________________________________  \nProsthetics, Orthotics and/or Splints Used    \nWheelchair and Seating Evaluation: Jill Sparacio, Jessica Pedersen, Mike Babinec, Julie Piriano (2003, 2007, 2014, 2018, 2024) Page 1 of 17  \nPatient Name:    \nCURRENT MOBILITY ASSISTIVE EQUIPMENT (MAE) / SEATING  \nCurrent Mobility Device 􀀁 None 􀀁 Cane 􀀁 Walker 􀀁 Stroller 􀀁 Manual W/C 􀀁 MWC w/ tilt 􀀁 MWC w/ recline  \n􀀁 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  \nManufacturer   Model   Type of control    \nSerial \\#   Color   Age   Additional Components    \nCondition of Current Mobility Device 􀀁 Good 􀀁 Fair 􀀁 Poor 􀀁 Disrepair 􀀁 Not safe / operational 􀀁 Irreparably damaged 􀀁 Other    \nProblems with Current Mobility Device    \nSeat Height   in. Seat Width   in. Seat Depth   in. Changes needed    \nCurrent Seating System   Age of Seating System   mo.  \nComponent Manufacturer Condition / Problems  \nSeat Cushion      \nPelvic Support      \nLateral Hip / Thigh / Knee Support      \nMedial Thigh Support      \nFoot Support / Straps / H","cbCaidQ92McgLLRu","https://ap.wps.com/l/cbCaidQ92McgLLRu","pdf",3301916,"English","# Patient Information\n# Medical History\n# Medical Systems and Functional Limitations\n# Current Mobility Assistive Equipment (MAE) / Seating\n# Home Environment\n# Community Environment","[{\"question\":\"What patient details are collected in this evaluation form?\",\"answer\":\"The form collects patient name, date of birth, sex, address, city/state/ZIP, phone contacts, physician and therapist information, and identifying medical record details.\"},{\"question\":\"How does the form document medical history for mobility and positioning needs?\",\"answer\":\"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.\"},{\"question\":\"What wheelchair and seating information is required for the assessment?\",\"answer\":\"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.\"}]","Wheeled Mobility and Seating Evaluation - Patient Intake and Wheelchair Seating Assessment Form | PDF",1791843969,6]