Seating Evaluation I.M.S. Clifton, NJ (973) 478-9219

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Seating Evaluation

Seating Evaluation

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Please fill out this Wheelchair Seating Evaluation Form

Information First Name * Last Name * Address City State/Province Zip Home Phone Work Phone Email Birth Date Sex
Female Male Height Weight

Primary Contact Primary Contact Relationship Home Phone Work Phone Email Referral Name Referral Phone

Please list applicable medical conditions Primary Diagnosis Additional Diagnoses Primary Reason for seeking a seating evaluation

Is the patient alert
Yes No Is the patient oriented
Yes No Can the patient propel a manual wheelchair well enough to navigate the inside of their residence
Yes No

Present Equipment Choose One

If you have equipment fill the following section to the best of your ability/recollection Manufacturer Model Serial Number Width Depth Date of Purchase Who was the payer Specialty Back Components? Specialty Cushion? Existing equipment issues Solutions Attempted?

Medical Review Past Applicable pastSurgeries Planned Applicable Surgeries Cognitive Level Vision Hearing Communication Sensation Skin Integrity History of Sores? Ability to do pressure relief Describe any interventions regarding pressure sores

Activities of Daily Living Eating Toileting Bathing Dressing

Additional Information Current Living Environment Projected Living Environment Transportation Can Client Drive? Walking Transfers Typical # of daily hours sitting in the chair? Does the patient typically sit in their wheelchair at home? Does the patient need the wheelchair to get around their residence? Wheelchair Propulsion Does the patient use their feet to propel or help propel the chair? Please provide any other pertinent details regarding propulsion

Refer to the image below for measurement A) Pelvic Width B) Chest Width C) Shoulder Width D) Head Width E) Seat to Top of Head F) Seat to Shoulder Hgt. G) Seat to Axilla H) Seat to ASIS I) Trunk Width J) Back to Anterior OIITs K) Seat Depth L) Back to Lateral Condyl of Knee M) Seat to Floor N) Foot Length O) Thigh Width

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