College for Vocational Training

Wheelchair assessment and referral form

Instructions
A current wheelchair assessment of a wheelchair must be conducted by a Physiotherapist must be completed for
or modifications (including new system seatings)
Information
First name Date of BirthHeight DiagnosisI Neurological factors
Indicative muscle tone: Hypertonic
Describe muscle tone:

Last NameDate of AssessmentWeight-

Hypotonic

Abs.

Fluctuating

Describe active movements affected by muscle tone:

Describe passive movements affected by muscle tone:

Describe reflexes present(if any):

II. Postural Control

Head control
Good
Fair Poor
None
Trunk control
Good Fair
Poor None
Upper extremities Good Fair
Poor None
Lower extremities Good Fair
Poor None
Description and pictoral representation of posture:

III.Medical surgical history and plans:

Is there any history of decubitus/skin breakdown? Yes
If yes please explain:

No

others

Describe orthopedic conditions and/ or range of motion requiring special consideration (i.e., contractures,
degree of spinal curvature, etc.):

Describe other physical limitation or concerns (i.e., respiratory):

Describe any recent changes in medical/Physical/functional status:

Brief description if the child/adult has undergone any surgery:

IV. Functional assessment

Ambulatory status: Non ambulatory With assistance
Community ambulatory
Description:

Short distance only

Indicate the childs /adults ambulatory potential: Already using a wheel chair
Expected in 1 year Not expected Expected in future __ Years.
Description:
IV. Functional assessment:
Is the child/adult totally dependent on W/C? Yes
If No, please explain:

No

Indicate the child/adults transfer capacities: Maximum assistance

Moderate assistance Minimum assistance None
Notes:
Is the child/adult tube fed? Yes
If yes please explain:
Feeding: Maximum assistance
Notes:

No

Moderate assistance

Minimum assistance

None

Dressing: Maximum assistance Moderate Minimum assistance

Notes: He needs full assistance in dressing and undressing.

None

Describe the activities performed in wheelchair: (Mobility,feeding,socializing with peers, school, home, family,
engaging in community activity)

TRANSPORTATION:
Car

Van

Bus

Bike

Other

Sits in wheelchair during transport

Tie Downs

Where is w/c stored during transport?

Self Driver
Drive while in Wheelchair
Employment:
Specific requirements pertaining to mobility

yes

no

School:
Specific requirements pertaining to mobility
Other:

FUNCTIONAL/SENSORY PROCESSING SKILLS:

Handedness:
Right
Left
NA Comments:
Functional Processing Skills for Wheeled Mobility
Processing Skills are adequate for safe wheelchair operation
Comments:

COMMUNICATION:
Verbal Communication
WFL receptive

WFL expressive

Difficult to understand

non-communicative

Uses an augmentative communication device

AAC Mount Needed:
SENSATION and SKIN ISSUES:
Sensation
Intact
Impaired
Absent
Hyposensate

Hypersensate

Defensiveness
Level of sensation:
Skin Issues/Skin Integrity
Current Skin Issues
Yes
Intact

Red area

Scar Tissue

No

Open Area

At risk from prolonged sitting

Where ___________________________

Pressure Relief:
Able to perform effective pressure relief :
Method:
If not, Why?:

History of Skin Issues

Yes

No
Where

________________________
When

_________________________

Yes

No

Hx of skin flap surgeries

Yes
No
Where ________________________
When _________________________

Complaint of Pain: Please describe

ADL STATUS (in reference to wheelchair use):

Indep

Assist

Unable

Indep
with
Equip

Not
assessed

Comments

Dressing
Eating

Describe oral motor skills

Grooming/Hygiene

Meal Prep
IADLS
Bowel Mngmnt:

Continent

Incontinent

Accidents

Comments:

Bladder Mngmnt:

Continent

Incontinent

Accidents

Comments:

CURRENT SEATING / MOBILITY:

Current Mobility Base:

None

Dependent

Dependent with Tilt

Current Condition of Mobility Base:

Current Seating System:
COMPONENT
MANUFACTURER/CONDITION
Seat Base
Cushion
Back
Lateral trunk supports
Thigh support
Knee support
Foot Support
Foot strap
Head Support
Pelvic Stabilization
Anterior Chest/Shoulder
Support
UE Support
Other
When relevant:
Overall seat height
Describe posture in
present seating system:

Manual

Scooter

Power Type of Control:

Age of Seating System:

Overall w/c length

V. Environmental assessment
Describe the place where Wheel chair is going to be used(home/school):

Overall w/c width

Is the home/School accessible for W/C? Yes

Are there ramps in home/School? Yes
No

No
Needs modification

RECOMMENDATION / GOALS :
POV
POWER WHEELCHAIR:

MANUAL WHEELCHAIR

POSITIONING SYSTEM(TILT/RECLINE)

SEATING

WHEELCHAIR SKILLS:
Indep

Assist

Dependent/
unable

N/A

Comments

Bed w/c Chair Transfers

w/c Commode Transfers
Manual w/c Propulsion:

Operate Scooter

UE or LE strength and
Arm :
left
right
endurance sufficient to participate in
Foot:
left
right
ADLs using manual wheelchair
Strength, hand grip, balance , transfer appropriate for use.

Both
Both

Living environment appropriate for scooter use.

Operate Power w/c: Std. Joystick

Safe

Functional

Distance

Operate Power w/c: w/ Alternative

Controls

Safe

Functional

Distance

MOBILITY/BALANCE:
Balance

Transfers

Ambulation
Sitting Balance:

Standing Balance

Independent

Independent

Min Assist

Ambulates with Asst

Min assist

Mod Asst

Ambulates with Device

Min Assist

Mod assist

Max assist

Indep. Short Distance Only

Mod Assist

Max assist

Dependent

Unable to Ambulate

Unable

Sliding Board

WFL
Uses UE for balance in sitting

Max Assist
Unable

Comments:

WFL

Lift / Sling Required

MAT EVALUATION

A
F

B
D

I
J

K L
E

M
N

A:
B:
C:
D.
E.
F.
G.
++

Measurements in Sitting:
Shoulder Width
Chest Width
Chest Depth (Front Back)
Hip width
Between Knees
Top of Head
Occiput
Overall width (asymmetrical width for
windswept legs or scoliotic posture

Left

Right

H:
I:
J:
K:
L:
M:
N:

Seat to Top of Shoulder

Acromium Process (Tip of Shoulder)
Inferior Angle of Scapula
Seat to Elbow
Seat to Iliac Crest
Upper leg length
Lower leg length

O: Foot Length
Additional Comments:

Hamstring flexibility: Pelvis to thigh angle

accommodate greater than 90

Describe Reflexes/tonal influence on body:

Thigh to calf angle

accommodate less than 90

COMMENTS:

POSTURE:

Anterior / Posterior

Obliquity

Rotation-Pelvis

P
E
L
V
I
S

Neutral
Anterior

Posterior

Fixed

WFL

R elev

Fixed

Other

Other

l elev

WFL

Right
Anterior

Fixed

Other

Partly Flexible

Partly Flexible

Partly Flexible

Flexible

Flexible

Flexible

TRUNK

Anterior / Posterior

Left
Anterior

Rotation-shoulders and upper

trunk

Left Right

Neutral
WFL Thoracic
Lumbar
Kyphosis
Lordosis

WFL
Convex
Convex
Left
Right
c-curve
s-curve

Left-anterior
Right-anterior

multiple
Fixed

Flexible

Fixed

Partly Flexible

Other

Partly Flexible

Flexible

Fixed

Flexible

Partly Flexible

Other

Other

Describe LE Neurological Influence/Tone:

Position

Windswept
Hip Flexion/Extension
Limitations:

H
I
P
S

Neutral

Abduc ADduct

Neutral Right Left

Fixed

Fixed

Other

Subluxed

Partly Flexible

Partly Flexible

Hip Internal/External
Range of motion Limitations:

Dislocated
Flexible

Knee

Flexible

R.O.M.

Foot Positioning
Left
KNEES
&

Right

WFL

WFL

Dorsi-Flexed

Plantar Flexed

Inversion

Eversion

ROM concerns:

WFL

Limitations
Limitations

FEET

COMMENTS:

Posture:
Good Head Control

HEAD

Functional

&
NECK

Flexed

Extended

Rotated L

Lat Flexed

Rotated R

at Flexed

Describe Tone/Movement
of head and Neck:

Adequate Head Control

Limited Head Control

L
R

Cervical Hyperextension

R.O.M. for Upper

Extremity
WNL
WFL
Limitations:

Upper
Extremity SHOULDERS

Left

Absent Head Control

Right

Functional
Functional
elev / dep
pro-retract
retract
subluxed

elev / dep
prosubluxed

UE Strength Concerns:
N/A
None
Concerns:
R.O.M.

ELBOWS
Left

Right

Describe
Tone/Movement of UE:

Strength concerns:
Left

Right

Strength / Dexterity:

WRIST
&
HAND

Fisting

Goals for Wheelchair Mobility

Independence with mobility in the home and motor related ADLs (MRADLs) in the community
Independence with MRADLs in the community
Provide dependent mobility
Provide recline
Provide tilt
Goals for Seating system
Optimize pressure distribution
Provide support needed to facilitate function or safety
Provide corrective forces to assist with maintaining or improving posture
Accommodate clients posture: current seated postures and positions are not flexible or will not tolerate corrective
forces
Client to be independent with relieving pressure in the wheelchair
Enhance physiological function such as breathing, swallowing, digestion
Simulation ideas:
Equipment trials:
State why other equipment was unsuccessful:

SEATING COMPONENT RECOMMENDATIONS AND JUSTIFICATION

Component

Seat Cushion

Manuf/mod/size

Justification
accommodate impaired
stabilize pelvis
sensation
accommodate obliquity
decubitus ulcers present
accommodate multiple
prevent pelvic extension
deformity
low maintenance
neutralize LE
increase pressure

distribution

Seat Wedge

accommodate ROM

Cover Replacement
Mounting
hardware
lateral trunk supports
headrest
medial thigh support
back
seat

Provide increased
aggressiveness of seat shape
to decrease sliding down in the
seat

protect back or seat cushion

fixed
swing away for:

Seat Board
Back Board
Back

attach seat platform/cushion to

w/c frame
attach back cushion to w/c
frame

mount headrest
swing medial thigh
support away

support cushion to prevent

hammocking

allows attachment of
cushion to mobility base

provide lateral trunk support

accommodate deformity
accommodate or decrease tone
facilitate tone

swing lateral supports

away for transfers

provide posterior trunk

support
provide lumbar/sacral
support
support trunk in midline
accommodate tone
removable for transfers

Lateral pelvic/thigh
support

pelvis in neutral
accommodate pelvis
position upper legs

Medial Knee
Support
Foot Support

decrease adduction
accommodate ROM

remove for transfers

alignment

position foot
accommodate deformity

stability
decrease tone
control position

Ankle strap/heel
loops
Lateral trunk
Supports

Anterior chest
strap, vest, or
shoulder retractors

Component

Headrest

Manuf/mod/size

support foot on foot support

decrease extraneous
movement
decrease lateral trunk leaning
accom asymmetry
contour for increased contact
decrease forward movement of
shoulder
accommodation of TLSO
decrease forward movement of
trunk

provide input to heel

protect foot
safety
control of tone
added abdominal
support
alignment
assistance with shoulder
control
decrease shoulder
elevation

Justification
provide posterior head support
improve respiration

Neck Support
Upper
Extremity
Support

placement of switches
safety
accommodate ROM
accommodate tone
improve visual orientation

decrease neck rotation

decrease forward neck flexion

decrease edema
decrease subluxation
control tone
provide work surface
placement for
AAC/Computer/EADL

decrease gravitational pull on

shoulders
provide midline positioning
provide support to increase
UE function

Pelvic
Positioner
Belt
SubASIS bar
Dual Pull

stabilize tone
decrease falling out of chair/
**will not decrease potential for
sliding due to pelvic tilting
prevent excessive rotation

pad for protection over boney

prominence
prominence comfort
special pull angle to control
rotation

Bag or pouch

Holds:
medicines
orthotics
changes

Arm trough
Posterior hand
support
tray
full tray
swivel mount

Other

provide posterior neck support

provide lateral head support
provide anterior head support
support during tilt and recline
improve feeding

special food
clothing

provide hand support in natural

position

diapers
catheter/hygiene
ostomy supplies

Recommendations/ Modifications in the W/C:

Signature of the PT