Clinical Information for Wheeled Mobility Page 1 of 6
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1 Clinical Information for Wheeled Mobility Page 1 of 6 PART A: PATIENT / PROVIDER INFORMATION - Please Print Name: Sponsor Soc. Sec. No: Address: City: St: Zip: Phone: ( ) Age: Sex: Height: Weight: Date Referred: Date of Eval: Physician: OT: PT: Referred By: Reason for Referral: Patient Goals: Caregiver Goals: PART B: MEDICAL HISTORY Dx: ICD-9: ICD-9: ICD-9: ICD-9: Hx / Progression: Recent / Planned Surgeries: Cardio-Respiratory Status: Intact Impaired PART C: CURRENT SEATING / MOBILITY: (Type Manufacturer Model) Chair: Age: w/c Cushion: Age: w/c Back: Age: Reason for: Replacement Repair Update Funding Source: PART D: HOME ENVIRONMENT House Apt Asst Living LTCF Alone w/ Family-Caregivers: Entrance: Level Ramp Lift Stairs Entrance Width: w/c Accessible Rooms: Yes No Narrowest Doorway Required to Access: PART E: COMMUNITY ADL TRANSPORTATION: Car Van Bus ADAPTED WITH: Chair Lift Ramp Ambulance Other* Driving Requirements: Employment / Educational Requirements: *Other:
2 Seating/Mobility Evaluation Page 2 of 6 PART F: COGNITIVE / VISUAL STATUS (Please check appropriate box and make comments as needed) Memory Skills Problem Solving Judgment Attention / Concentration Vision Hearing Other Intact Impaired Comments PART G: ADL STATUS (Please check appropriate box and make comments as needed) INDEP ASSIST UNABLE Comments / Other AT Equipment Required Dressing Bathing Feeding Grooming/Hygiene Toileting Meal Prep Home Management Bowel Management Continent Incontinent Bladder Management Continent Incontinent PART H: MOBILITY SKILLS (Please check appropriate box and make comments as needed) Bed w/c Transfers w/c Commode Transfers Ambulation Manual w/c Propulsion Operate Power w/c w/ Std. Joystick Operate Power w/c w/ Alternative Controls Able to Perform Weight Shifts Hours Spent Sitting in w/c Each Day: INDEP ASSIST UNABLE N/A COMMENTS Device: Type: Comments: PART I: SENSATION Intact Impaired Absent Hx of Pressure Sores Yes No Current Pressure Sores Yes No
3 Seating/Mobility Evaluation Page 3 of 6 PART J: CLINICAL CRITERIA / ALGORITHM SUMMARY 1. Is there a mobility limitation causing an inability to safely participate in one or more Mobility Related Activities of Daily Living in a reasonable time frame? YES NO N/A 2. Are there cognitive or sensory deficits (awareness / judgment / vision / etc) that limit the user s ability to safely participate in one or more MRADL s / ADL s? If yes, can they be accomodated / compensated for to allow use of a mobility assistive device to participate in MRADL s? 3. Does the user demonstrate the ability or potential ability and willingness to safely use the mobility assistive device? 4. Can the mobility deficit be sufficiently resolved with only the use of a cane or walker? 5. Does the user s environment support the use of a: MANUAL WHEELCHAIR POV POWER WHEELCHAIR 6. If a manual wheelchair is recommended, does the user have sufficient function / abilities to use the recommended equipment? 7. If a POV is recommended, does the user have sufficient stability and upper extremity function to operate it? 8. If a power wheelchair is recommended, does the user have sufficient function / abilities to use the recommended equipment? PART K: RECOMMENDATIONS / GOALS MANUAL WHEELCHAIR POV POWER WHEELCHAIR POSITIONING SYSTEM (TILT/RECLINE/ELEV/STANDING) SEATING
4 Seating/Mobility Evaluation Page 4 of 6 MAT EVALUATION: SITTING OR SUPINE HEAD & NECK POSTURE: FUNCTION: Functional Flexed Good Head Control Adequate Head Control Extended Rotated Limited Head Control Absent Head Control Laterally Flexed Cervical Hyperextension UPPER EXTREMITY SHOULDERS: WFL Range of Motion (R.O.M.): Elev/dep Pro/retract Strength: Subluxed ELBOWS: Impaired Range of Motion (R.O.M.): WFL Strength: WRIST & HAND Impaired Strength/Dexterity: WFL TRUNK Anterior / Posterior / Rotation - Neutral Forward Forward WFL Thoracic Lumbar WFL Convex Convex Kyphosis Lordosis Fixed Flexible Fixed Flexible Fixed Flexible Partly Flexible Other Partly Flexible Other Partly Flexible Other
5 Seating/Mobility Evaluation Page 5 of 6 MAT EVALUATION: () PELVIS ANTERIOR / POSTERIOR OBLIQUITY ROTATION Neutral Posterior Anterior WFL Lower Rt. Lower WFL Fixed Flexible Fixed Flexible Fixed Flexible Partly Flexible Other Partly Flexible Other Partly Flexible Other HIPS POSITION WINDSWEPT RANGE OF MOTION Neutral ABduct ADduct Neutral Flex: o o Ext: o o Fixed Subluxed Fixed Partly Flexible Partly Flexible Dislocated Flexible Other Int R: o o Flexible Ext R: o o KNEES & FEET KNEE R.O.M. FOOT POSITIONING LEFT RIGHT LEFT RIGHT WFL WFL WFL WFL Dorsi-Flexed Dorsi-Flexed Flex o Flex o Plantar Flexed Plantar Flexed Ext o Ext o Inversion Inversion Strength: Eversion Eversion Hamstring R.O.M. Limitations: (Measured at o Hip Flex) Foot Positioning Needs: MOBILITY BALANCE TRANSFERS AMBULATION Sitting Balance Standing Balance Independent Unable to Ambulate WFL WFL Min Assist Ambulates with Assistance Min Support Min Support Max Assist Ambulates with Device Mod Support Mod Support Sliding Board Independent without Device Unable Unable Lift / Sling Required Indep. Short Distance Only
6 Seating/Mobility Evaluation Page 6 of 6 MAT EVALUATION: () MEASUREMENTS A B D E F G H I J K L C M N Measurements in Sitting: A Shoulder Width B Chest Width C Chest Depth (Front Back) D Asymmetrical Hip Width** D Hip Width E Between Knees F Top of Head G Occiput ** Asymmetrical Width: i.e., windswept or scoliotic posture; measure widest point to widest point H I J K L M N O O Degree of Hip Flexion Top of Shoulder Acromion Process (Tip of Shoulder) Inferior Angle of Scapula Elbow Iliac Crest Sacrum to Popliteal Fossa Knee to Heel Foot Length Neuro-Muscular Status: Tone: Reflexive Responses: Effect on Function: Additional Comments: Physical / Occupational Therapist: Date: Phone: ( ) Physician Signature: (I have read and concur with the above assessment) Date: Phone: ( ) Note: HIPAA authorization requirements do not apply to protected information used for treatment, payment, or health care operations including medical records requested for the provision of health care services. Privacy Act Statement: This information is protected under the Privacy Act of 1974 and shall be handled as for official use only. Violations of this may be punishable by fines, imprisonment, or both.
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Feet facing forward on bolts General athletic stance for pushing and pulling Feet facing at an angle Movement transition for rotational and agility Wide in-line stance Simulate forward weight shift running
Range of motion and positioning
Range of motion and positioning Teaching guide To use this lesson for self-study, the learner should read the material, do the activity, and take the test. For group study, the leader may give each learner
1. Can self-propel, or use their foot to push (punt), a standard manual wheelchair 1 and be safe and able to do essential daily tasks.
Disability Support Services Equipment and Modifications Competency Framework Wheeled Mobility and Postural Management Introduction The Wheeled Mobility and Postural Management Credential recognises that
Phase 1 Initiating Normal Spinal Motion. Activities to Avoid or Minimize. Good choices to make
Phase 1 Initiating Normal Spinal Motion Activities to Avoid or Minimize 1. Sitting 2. Standing with weight on one foot 3. Reading on back with head flexed forward 4. One sided sports (always practice both