ATP MOBILITY ASSESSMENT FORM Name: Date: Address: City: State: Zip: DOB: Weight: Height: Gender: PLACE OF SERVICE: Assisted Living Home SNF : Physician: NPI: Address: City: State: Zip: Primary Insurance: Policy: Secondary Insurance: Policy: Diagnosis: Skin Integrity: CURRENT MOBILITY DEVICE Cane Crutches Walker Manual Wheelchair POV/Scooter Power Wheelchair Make/Model: S/N: Seat Height: Width: Depth: Back Height: Seating System: Problems noted with current seating and/or mobility device: WHEELCHAIR USAGE AND ENVIRONMENTAL / ACCESSIBILITY CONSIDERATIONS Where used: Home School Work Hours home alone: All day >12 Hrs >8 Hrs >4 Hrs >2 Hrs <2 Hrs Total usage: All day >12 Hrs >8 Hrs >2 Hrs <2 Hrs Minimal Transfers: Ind. Assist. Stand. Lateral Slide Dep. /Device Home entrance: # Stories: # Stairs: Ramp: Floor coverings: Transportation: Public Bus Van Auto Airline Driver in w/c Transfer to driver seat Passenger in w/c Transfer to passenger seat Page 1 of 7
What are your mobility limitations an how does this affect your ability to move throughout your home to participate in your activities of daily living (toileting, feeding, dressing, grooming and bathing)? Toileting: Grooming: Bathing: Dressing: Feeding: KEY: 1 = Increased time 2 = Distance 3 = Balance 4 = Safety 5 = Pain 6 = Shortness of Breath Have you tried or do you use a cane or walker in your home? Yes No Can you walk without the assistance of a caregiver? Yes No What distance are you able to walk without rest? What physically limits your ability to walk or walk further? Non-functional leg(s) Loss of lower extremity Weakness in leg(s) Extremity pain Back pain Balance / Fear of falling Shortness of breath Chest pain What other factors limit your ability to walk or walk further? Cannot hold equipment Cannot lift equipment Distance to room Floor covering(s) Have you tried or do you use a manual wheelchair in your home? Yes No Manual Wheelchair Make: Model: Rental/Trial Customer Owned Can you self-propel without the assistance of a caregiver? Yes No What distance are you able to self-propel without rest? What physically limits your ability to self-propel / self-propel further? Non-functional arm(s) Non-functional Leg(s) Weakness in arm(s) Weakness in leg(s) Pain in arm(s) Pain in leg(s) Shortness of breath Chest Pain What limits your ability to self-propel / self-propel further? Cannot grip handrim Cannot repeat motion Distance to room(s) Floor covering(s) Page 2 of 7
Manual Wheelchair Base Trialed: Frame Options / Accessories Tilt in space Adjustable angle back Manual reclining back Seat Width Seat Depth Arm Options / Accessories Fixed height arms Adjustable height arms Reclining arms Footrest / Legrest Options / Accessories Foot platform Swing-away footrest Adj. angle footplate(s) Large footplate Heel loops Calf / Leg strap Manual ELR s Articulating ELR s Wheel Options / Accessories Adjustable axle Wheel lock extensions Grade aids Coated handrim(s) Projection handrim(s) Spoke protectors Flat free inserts Shock absorber(s) Amputee adapter Miscellaneous Options / Accessories Pelvic belt Anti-tippers Vent tray O2 Tank holder IV Hanger Cane / Crutch holder Page 3 of 7
Have you tried, or do you use a POV (Scooter) in your home? Yes No Are you able to safely maneuver a POV (Scooter) in your home? Yes No SCOOTER / POV Make: Model: Trial Customer Owned Demonstrated the ability to safely operate all components of the scooter / POV Yes No Demonstrated the ability to safely transfer to/from the scooter / POV Yes No Demonstrated improved ability to perform MRADL's with the scooter / POV Yes No What physically limits your ability to operate a scooter / POV? Non-functional arm(s) Weakness in arm(s) Pain Limited range of motion Limited balance What other factors limit your ability to use a scooter / POV? Cannot grip tiller Turning radius Seating required Have you tried, or do you use a power wheelchair in your home? Yes No Are you able to safely maneuver a power wheelchair in your home? Yes No POWER WHEELCHAIR Make: Model: Trial Customer Owned Demonstrated the ability to safely operate a power wheelchair Yes No Demonstrated the ability to transfer to/from a power wheelchair Yes No Demonstrated improved ability to perform MRADL's with the recommenced PWC Yes No What physically limits your ability to operate a power wheelchair? Non-functional arm(s)* Spasticity* Incoordination/Tremors* Weakness-hand/arm(s)* Limited range of motion Pain* Limited balance* * What other factors limit your ability to use a power wheelchair? Cannot grip control* Special seating req'd* Power seat functions* * * * * An OT / PT Seating & Wheeled Mobility Evaluation is required Page 4 of 7
Power Wheelchair Base Trialed: Power Seating Functions Power Tilt in Space Power Reclining Back Power Seat Elevator Power Stand System 1 Pwr function thru drive control 2+ Pwr functions thru drive control Frame Options / Accessories Seat Width " Seat Depth " Arm Options / Accessories Fixed Height Arms Adjustable Height Arms Reclining Arms Footrest / Legrest Options / Accessories Foot Platform Swing-away Footrest Manual ELR's Power ELR's Power Foot Platform Adj. Angle Footplate(s) Large Footplate(s) Heel Loops Calf / Leg Strap Wheel Options / Accessories Flat Free Inserts Shock Absorber(s) Battery, Electronics & Drive Control Options Swing-away Mount Joystick Alternative Drive Control Gel Cell Batteries Miscellaneous Options / Accessories Pelvic Belt Vent Tray O2 Tank Holder IV Hanger Cane/Crutch Holder Page 5 of 7
MEASUREMENTS LEFT RIGHT LEFT RIGHT A Max. sitting height J Forearm depth B Occiput height K Elbow height C Head width L Thigh depth D Shoulder width M PSIS height E Chest width N Ischial depth F Trunk depth O Hip width G Shoulder height P Lower leg length H Axilla height Q Foot depth I Scapular height R A C B F D G/R G/L J/R J/L H/L E H/R M/R M/L K/R K/L I/L O* I/R N/R L/R N/L L/L Q/R P/R Q/L P/L Page 6 of 7
Seating and Positioning Seat Cushion / Support Solid Seat Back Cushion / Support Positioning Accessories Headrest / Support Multi-axis, Removable and/or Swing-away Headrest Hardware Lateral Trunk Support(s) Shoulder Harness/Chest Strap Lateral Thigh Support(s) Medial Thigh Support Swing-away / Flip-down Bracket(s) Arm Trough 1/2 Tray UE Support Full Tray UE Support Residual Limb Support Foot Positioners Equipment Recommendation: See Order Form(s) I acknowledge that I have reviewed this entire document, agree with the information contained herein and that the answers I have provided are accurate and truthful. I am able to safely / independently operate the recommended equipment in my home and am willing to use it routinely I am not able to safely or independently use the recommended equipment within my home I do not wish to use the recommenced equipment in my home and require it for use in the community only Client Signature: Date: Name of Representative completing the Assessment: ATP Certification #: Signature: Date: Page 7 of 7