Fox Medical An Independent Company for Independent Living

 

 

 

 

 
 
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Wheelchair Evaluation Form

*First Name:
*Last Name:
Street Address:
Address (2nd):
City:
State/Province:
Zip Code:
Age:
Social Security Number:
*Home Phone:
*E-mail:
Weight:
Height:
(See Diagram Below) A.Hip Width:
B.Chest Width:
C.Thigh Width:
D.Leg length below the knee:
E.Thigh length:
F.Axilla to buttocks:
G.PSIS:
H.Shoulder height:
I.Head height:

 
Living Situation: House
Apartment Alone
With
Has Attendant: Yes No
For
Can they walk at all?: Yes No

How far?
If nonambulatory, for how long?:
Is the person on Oxygen?: Yes No
What kind of things do they need help with?:
Do they transfer independently?: Yes No
Do they have any steps or ramps at their residence?:
Current wheelchair type?: 
All Medical Diagnoses: 
Any skin problems?: 
Any swelling?: Yes No

Where?
Any pain?: Yes No

Where?
What will power wheelchair enable them to do that now they cannot?:
Wheelchair Accessories Needed:
Comments:

Thank You!
*This field is required.

 

 

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